Tag: Medicare

Hospitals Often Retain Accreditation Despite Safety Violations

Hospitals Maintain Accreditation Despite Safety Violations | DAS Health

The Joint Commission accredits nearly 80% of U.S. hospitals, but rarely revokes or alters accreditation when state or federal inspectors identify safety violations, The Wall Street Journal reported.

According to a Journal analysis of hundreds of inspection reports, about 350 hospitals maintained accreditation in 2014 despite Medicare deviations, and more than a third of those had further violations in 2015 and 2016. In one case, the Joint Commission allowed Cooley Dickinson Hospital in Northampton, Mass., to continue claiming full accreditation despite being out of compliance with Medicare safety requirements. CMS had threatened to cut off Medicare funding after a pregnant woman with pre-eclampsia died when she wasn’t treated for high blood pressure, and two infants died six weeks apart — all during late 2013 and early 2014.

Mark Chassin, president and chief executive of the Joint Commission, told the Journal the organization’s aim is to prevent problems rather than punish hospitals by withdrawing accreditation. Sen. Chuck Grassley (R-Iowa) has promised to look into ways to improve the system, the newspaper says.

Many people look for Joint Commission accreditation as a sign that a hospital has high standards of patient care and safety. If a hospital is out of compliance with regulatory requirements but still carries the Joint Commission seal of approval, patients may not be aware of potential risks.

Hospitals have often been at odds with government agencies and the public when it comes to balancing concerns of safety with those of privacy. To the dismay of some, CMS dropped plans to make reports by public healthcare accreditors public in its 2018 patient payment final rule. The agency had proposed that all accreditors publicly report findings from hospital inspections to ensure patients know of problems, but withdrew the plan because federal law bars agencies from revealing third-party audit results.

Last month, United Medical Center refused to address safety concerns and reports of dangerous staff errors that prompted District of Columbia officials to close the hospital’s obstetrics ward. Often the disagreement hinges on the level of detail. The American Hospital Association says it supports making hospital quality data public, but not necessarily detailed inspection reports that the public may not easily understand.

Still, the move toward value-based care has often included a push toward more transparency, and that has spurred some healthcare organizations to publish patient feedback — both praise and complaints. Geisinger, for example, began making patient reviews available to its physician network in mid-2015. The health system began airing the data for all to see later that year. Greg Burke, chief patient experience officer at Geisinger, told Healthcare Dive in November patient stories make a greater impression on clinicians than patient survey data, though.

As the examples of Cooley Dickinson Hospital and United Medical Center show, hospital quality issues can be life and death matters. According to a study in PLOS One, patients admitted to low-performing hospitals are three times more likely to die and 13 times more likely to experience complications than patients in high-performing facilities. Some of the best performing hospitals served low-income and minority populations, while some of the worst performers served high-income, white communities. The results pointed to the need for greater transparency on quality in healthcare.

While problems persist, programs like CMS’ hospital star rating system have focused a beam on quality.  A November 2016 Joint Commission report cited significant strides in hospital quality and safety, noting so much improvement that 20 accountability measures had been retired, reducing to 29 the number the group tracks. The report detailed the results of more than 3,300 Joint Commission-accredited hospitals’ 2015 performance on individual measures of patient care.

Study: Value-Based Programs May Harm Practices That ‘Disproportionately Serve High-Risk Patients’

Value-based payment programs may financially harm practices that disproportionately serve high-risk patients.

  • A new JAMA report that reviewed the first year of the Medicare Physician Value-Based Payment Modifier (PVBM) Program found providers who served “more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.”
  • The finding led to fewer bonuses and more penalties for high-risk practices.
  • The study authors said value-based payment programs may financially harm practices that “disproportionately serve high-risk patients.”



CMS created the PVBM to measure the quality and cost of care provided to Medicare beneficiaries. The program bases payments on providers’ performance on quality and cost measures and rewards quality performance and lower costs.

The agency began to phase in practices to the program in 2015 based on 2013 performance and then planned to expand it to solo practices and later to physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists.

The study reviewed 899 physician practices with nearly 5.2 million beneficiaries that participated in the PVBM, a mandatory pay-for-performance program. Authors studied program payments in 2015 and compared them to 2013 fee-for-service (FFS) Medicare numbers.

The JAMA study’s finding that more medically high-risk patients had lower quality and higher costs is eye-opening. Those patients are usually the most costly and payment models will need to figure out ways to reduce those costs while not penalizing physicians if value-based programs are successful. A payment model that only lowers costs and improves care to healthy people won’t move the needle.

Even worse, if physicians are penalized, what incentive do doctors have to care for the sickest Medicare patients?

The JAMA report will likely not quell physician fears about how value-based programs may lead to lower Medicare payments. It also won’t satisfy individuals concerned that changes to the healthcare system may harm the most vulnerable, which is always a worry when there are major healthcare changes.

The JAMA study isn’t the first to show value-based programs as a mixed bag. Recent studies have shown that it hasn’t consistently improved outcomes and costs.

One key finding about value-based care so far has been that experience in the model plays an important role in whether a provider has success. Organizations with the most success under value-based programs have often spent years creating clinically integrated networks, James Landman, director of healthcare finance policy at the Healthcare Financial Management Association, recently told Healthcare Dive.

“If you look at the data for the Medicare Shared Savings Program, which is the biggest of the ACO programs under CMS, there is a correlation between time spent in the program and the ability to generate savings,” Landman said.

CMS is watching the results of value-based payment models like PVBM closely. The federal agency hopes to transfer 50% of traditional FFS Medicare payments to alternative payments models by next year.

CMS has slowed down the move to value-based payments, but that’s more due to the change in administration and slowly grinding gears of government than a move away from value-based programs.The federal agency has delayed the start of some programs to next year as well as paused expanding others.

With Tom Price in Charge at the HHS, Doctors are Winning in Washington

Price is listening to physicians’ concerns about issues such as Medicare payment rules under MACRA and burdensome electronic health record requirements.
Photo from NPR.org

When Tom Price, an orthopedic surgeon, was named secretary of Health and Human Services earlier this year, doctors had high hopes that he would look out for their interests. That’s exactly what’s happening: With Price in charge at HHS, doctors are winning in Washington.

While the fight over the repeal of the Affordable Care Act has raged loudly and publicly in Washington, Price has been working quietly to reverse other Obama administration efforts, acting to protect doctors from regulations put in place in the prior eight years, according to STAT.

Price is listening to physicians’ concerns about issues such as Medicare payment rules under MACRA and burdensome electronic health record requirements, STAT said.

Among the actions he has taken:

  • An American Medical Association committee was given more power over how much the federal government pays for different medical services.
    He has retroactively reversed certain Medicare rules to ensure some physicians no longer face penalties they would otherwise have had to pay.
    Price has proposed using almost $1 billion in savings that would be achieved through cuts to certain hospital payments to boost spending on physicians.
  • While many doctors vehemently oppose Republican efforts to repeal the ACA, they are thrilled at the regulatory rollbacks.
  • Hospitals, however, haven’t fared as well, with a proposal that would result in major cuts to hospital payments. A proposed Outpatient Prospective Payment rule, released in July, would significantly cut 340 billion drug discount payment rates to hospitals and may harm safety-net hospitals’ ability to treat low-income patients.

Quality Payment Program Hardship Exception Application for 2017 Now Open

Quality Payment Program Hardship Exception Application for the 2017 transition year is now available
Photo from CMS.gov

Clinicians Can Now Submit Quality Payment Program Hardship Exception Applications

The Quality Payment Program Hardship Exception Application for the 2017 transition year is now available on the Quality Payment Program website.

MIPS eligible clinicians and groups may qualify for a reweighting of their Advancing Care Information performance category score to 0% of the final score, and can submit a hardship exception application, for one of the following specified reasons:

  • Insufficient internet connectivity
  • Extreme and uncontrollable circumstances
  • Lack of control over the availability of Certified EHR Technology (CEHRT)

There are some MIPS eligible clinicians who are considered Special Status, who will be automatically reweighted (or, exempted in the case of MIPS eligible clinicians participating in a MIPS APM) and do not need to submit a Quality Payment Program Hardship Exception Application.


About the Hardship Exception Application Process

In addition to submitting an application via the Quality Payment Program website, clinicians may also contact the Quality Payment Program Service Center and work with a representative to verbally submit an application.

To submit an application, you’ll need:

  • Your Taxpayer Identification Number (TIN) for group applications or National Provider Identifier (NPI) for individual applications;
  • Contact information for the person working on behalf of the individual clinician or group, including first and last name, e-mail address, and telephone number; and
  • Selection of hardship exception category (listed above) and supplemental information.

If you’re applying for a hardship exception based on the Extreme and Uncontrollable Circumstance category, you must select one of the following and provide a start and end date of when the circumstance occurred:

  • Disaster (e.g., a natural disaster in which the CEHRT was damaged or destroyed)
  • Practice or hospital closure
  • Severe financial distress (bankruptcy or debt restructuring)
  • EHR certification/vendor issues (CEHRT issues)

Please note: Once an application is submitted, you will receive a confirmation email that your application was submitted and is pending, approved, or dismissed. Applications will be processed on a rolling basis.


Explanation of Special Status Calculation

The Centers for Medicare and Medicaid Services (CMS) has introduced new information on the Quality Payment Program website that indicates whether clinicians have “special status” and can therefore be considered exempt from the Quality Payment Program.

To determine if a clinicians’ participation should be considered as special status under the Quality Payment Program, CMS retrieves and analyzes Medicare Part B claims data. A series of calculations are run to indicate a circumstance of the clinician’s practice for which special rules under the Quality Payment Program will affect the number of total measures, activities or entire categories that an individual clinician or group must report. These circumstances are applicable for clinicians in: Health Professional Shortage Area (HPSA), Rural, Non-patient facing, Hospital Based, and Small Practices.

For more information, please visit the Quality Payment Program website.


For Physicians, Rates Nearly the Same for Medicare and Medicare Advantage

Medicare and Medicare Advantage Plans Cost | DAS Health

When it comes to payment rates, physicians aren’t seeing much of a difference between traditional Medicare and Medicare Advantage plans, according to a new study.

Advantage plans managed by private insurers pay doctors prices similar to Medicare rates, according to the study led by University of Southern California researchers, which was published in JAMA Internal Medicine. However, on some services or equipment, commercial insurers have an advantage, the study found.

“With 1 in 3 beneficiaries enrolled in Medicare Advantage, it is important to look under the hood and get a better understanding of how these plans operate,” Erin Trish, the study’s lead author and an assistant research professor at the USC Schaeffer Center for Health Policy and Economics, said in a university announcement.

“We found that physician reimbursement rates in Medicare Advantage are very similar to traditional Medicare. This is very different than what we see in the commercial insurance market, where insurers tend to pay physicians more than Medicare—sometimes much more,” she said.

In the study, researchers analyzed a sample of 144 million claims from 2007 to 2012 in metropolitan areas and compared reimbursement rates for 11 common procedures. They found mean Medicare Advantage reimbursement rates nearly matched the traditional Medicare rate in many cases, such as the rate for an office visit, which was 97% of the Medicare rate.

Those findings raise the question of how reforms under discussion, which would transition the program toward a premium support model, could affect how physicians and other clinicians are paid, the study said.

The study also looked at prices paid for commercial insurance patients. In general, commercial insurers paid higher prices for procedures. However, for a few services, commercial prices were lower than traditional Medicare.

Senate Revises Healthcare Bill, Keeps Cruz Amendment for Skinny Coverage

Ted Cruz | DAS Health
Photo from Salon.com

The Senate health bill unveiled Thursday keeps a controversial amendment put forward by Senators Ted Cruz and Mike Lee to allow insurers to sell bare-bones plans to one segment of the population while offering coverage to the healthier sector at lower premium rates.

Provider and payer organizations that have weighed in on the amendment are against it, saying Cruz’s proposal would result in higher premiums for people with serious and chronic conditions.

This is because the amendment allows younger and healthier members to purchase non-ACA compliant plans that have lower premiums but fewer benefits.

Those with chronic or pre-existing conditions would purchase ACA-compliant plans that keep essential benefits. Insurers would be prohibited from setting premiums based on health status. Opponents said premiums would have to rise for all beneficiaries.

The bill would establish a federally funded high-risk pool in states to help offset the expense of coverage of higher-risk enrollees.

“This same kind of risk pool segmentation occurred prior to enactment of the ACA when 35 states operated high-risk pools for persons unable to obtain insurance on the private market,” said the July 12 letter to Senators from 13 groups including AARP and the American Cancer Society. “In that experience, most of those states could not provide sustained funding support and were forced to limit enrollment, reduce benefits, create waiting lists, and raise premiums and out-of-pocket costs to the point of unaffordability.”y

Insurers have also voiced their opposition in letters to Cruz.

America’s Health Insurance Plans said products governed by different rules and stands would further destabilize the individual market and increase costs for those with pre-existing conditions, according to the document obtained by The Washington Post.

Scott P. Serota, the president and chief executive of the Blue Cross Blue Shield Association also said the Cruz plan could make coverage unaffordable for people with pre-existing conditions.

Cost-sharing subsidies, of critical importance for insurers looking to remain in the exchange market, still disappear in two years under the revised Senate bill. The federally-funded CSRs allow insurers to give lower income beneficiaries a break in the cost of deductibles and out-of-pocket expenses.

The Senate bill revises a House bill released in May, but retains many of its provisions.

It keeps deep cuts to Medicaid, turning the federal entitlement program to state control that is federally funded. The funds would be capped per state based on the number of Medicaid beneficiaries.

Planned Parenthood would be banned from the Medicaid program for one year.

Also eliminated is Medicaid expansion starting in 2021, which was adopted by 31 states and the District of Columbia.

Providers have credited the ACA’s Medicaid expansion with helping to lower the amount of uncompensated cost of care.

On its website, the American Hospital Association asks members to click to tell senators they oppose the Better Care Reconciliation Act.

Former Centers for Medicare and Medicaid Services Acting Administrator Andy Slavitt tweeted, “The Senate Trumpcare bill amendment was just released & it went from very bad to unworkably bad. First analysis.”

The revised bill retains some of the Affordable Care Act taxes on the wealthy to pay for provisions.

The legislation retains a 3.8 percent tax on net investment income for individuals earning more than $200,000 and couples earning more than $250,000; and an 0.9 percent surtax for the Medicare insurance program for the elderly on people with those incomes, according to Reuters.

Under the Senate bill, insurance subsidies based on income would be scaled back to 350 percent of the federal poverty level, according to Politico.

The revised Senate bill gives $45 billion for opioid funding as opposed to the $2 billion in the original bill, Politico reported.

It keeps a tax break for health insurance executives.

It would allow consumers to receive tax credits to purchase catastrophic health plan coverage and would also allow people to use health savings accounts to pay for premiums.

The individual and employer mandates to buy insurance goes away, but individuals who drop their coverage would be unable to purchase new coverage for six months.

The Senate is expected to vote on the bill next week after the Congressional Budget Office scores the financial and coverage impacts of the bill.

Senate Majority Leader Mitch McConnell can afford to lose only two votes. Last month at least 10 Senators opposed an earlier version of the bill.

The CBO estimated the earlier Senate bill would leave 22 million more people uninsured over a decade compared to the ACA. This bill never made it to a vote but was scrapped before the July 4 recess.