Archive for October, 2014

ICYMI: Last 2 Weeks’ Hot Stories in Health Law

October 3, 2014 Leave a comment

In the roller coaster world of health law, there are always a lot of hot stories — many more than what I list.  And my list will be different from yours.

In any event, here are 20 stories from the last 2 weeks that you would not want to have missed (in no particular order) (why 2 weeks?  because I got so busy dealing with my own hot stories in health law that I missed last week) :

  1. HHS issues guidance on same sex spouses and HIPAA — “The HIPAA Privacy Rule contains several provisions that recognize the integral role that family members, such as spouses, often play in a patient’s health care. …   The term marriage includes both same-sex and opposite-sex marriages, and family member includes dependents of those marriages.”  The bureaucracy churns along in an objective, nonjudgmental manner to give practical meaning to the Supreme Court’s decision in United States v. Windsor (which held DOMA unconstitutional).
  2. Think Further — I have read about the The Fred Alger Management Team’s Think Further project.  Recently, they have asked what innovative changes would be expected that the medical and healthcare industry will be going through over the next 50 years.  A number of bloggers are talking about the results.  I think you will them interesting also.
  3. Medicaid expansion gain momentum in initially reluctant states — As Reuters says “money talks” and Medicaid expansion has meant big federal subsidies.  The bottom line, of course, even for the jaded Republican flatworlders, is to reduce the uninsured and somehow move from sick care to health care.  In addition, the New York Times reports more insurers are expected to enter the exchanges , and Health News Florida reports that four new insurers have entered the Florida marketplace.  Alabama gubernatorial candidate Parker Griffith has expressed his desire to expand Medicaid — by taking advantage of the funds available from the Affordable Care Act.  (OK — expanding healthcare has always been the goal, and that’s a good thing.  But the funds have always been there, so why the 4-year delay?)
  4. Four more hospital systems recently have dropped out of the Pioneer Accountable Care Organization program — “Three years after the Centers For Medicare & Medicaid Services selected 32 groups to participate in the Pioneer Accountable Care Organization Model program, they are down to 19 players. Officials say that navigating the program’s rules has proved challenging.”  Frankly, ACOs work best with physicians who try to control costs by reducing unnecessary, expensive hospital procedures and admissions, so hospitals dropping out of ACOs should not surprise anyone.  And, as an aside, hospitals have been engaging in full-scale war against physicians for some time — they have the time, the money, and the manpower to marginalize the independent role of physicians in healthcare, and that would be an unfortunate outcome for America.
  5. Obamacare reduces hospitals’ uncompensated care costs — The Washington Post’s Wonkblog reports  “The Obama administration is projecting that hospitals will face $5.7 billion less in uncompensated care costs than they otherwise would have in the first full year of the Affordable Care Act’s coverage expansion.  It is no surprise that the reduction has been larger in those which have expanded Medicaid.
  6. ACO “experiment” rewards better health care at lower costs — The major goal of Obamacare was to incentivize patients and healthcare providers to care about health care rather than sick care.  ACOs were an important component of that goal.  It seems that they may be working.
  7. Involving patients in their care can result in better, more efficient health care outcomes — According to the Health Affairs Blog,   “There is growing evidence that patients, once engaged, take better care of themselves. They’re more likely to monitor their own health, take their medicines, and communicate more thoroughly with their care providers. They have a better understanding of the treatment strategy. And they are more likely to participate in clinical studies or other research to find better, more efficient treatments.”
  8. 7th Circuit Court of Appeals rejects physician lawsuit challenging the delay of Obamacare’s employer mandate — The Association of American Physicians and Surgeons, which brought the lawsuit, argued that the delay could hurt doctors financially.  The physicians’ case is similar to the one that House Republicans plan to file against the President.  The appeals court’s opinion was the equivalent of asking the plaintiffs, “seriously?”
  9. Gynecologists continue to employ morcellators after FDA warning — WSJ reports that “[d]octors nationwide are still using a gynecological tool [morcellators] months after the U.S. Food and Drug Administration warned that it can spread undetected cancer…”  Morcellators are used to remove common benign uterine growths known as fibroids, often in minimally invasive hysterectomies.  The FDA warned that the tool can spread undetected cancer.
  10. Consumer Group Sues 2 More Calif. Plans Over Narrow Networks — Kaiser Health News reports about two lawsuits filed in Los Angeles by a consumer advocacy group, Consumer Watchdog, against insurers Cigna and Blue Shield of California because they “misled consumers about the size of their networks of doctors and hospitals, leaving enrollees frustrated and owing large bills.”  One of the ways insurers are controlling costs (and the cynical say fighting Obamacare) is to reduce their network size.
  11. Debut of the “Open Payments” Website — CMS launched its national databank containing information on the financial relationships between physicians (which includes dentists, chiropractors, and other physician specialties) and teaching hospitals, applicable manufacturers, and group purchasing organizations as required by the Physician Payments Sunshine Act.  I have previously blogged about Open Payments and transparency.
  12. Oklahoma District Court Rules Against Subsidies for Federal Exchanges — This is another case in the controversy (previously commented on) of whether consumers in states that refused to set up their own insurance exchanges are entitled to federal subsidies when they purchase health insurance from the federally run exchange.  These cases will likely put Obamacare in the crosshairs of the U.S. Supreme Court again.
  13. OIG Proposes Revisions to Anti-Kickback Safe Harbors and Civil Monetary Penalties — OIG states that its goal in proposing the revisions “is to protect beneficial arrangements that enhance the efficient and effective delivery of health care and promote the best interests of patients, while also protecting the Federal health care programs and beneficiaries from undue risk of harm associated with referral payments.”  The proposed rules also contain a revised definition of “remuneration.”
  14. Medicare Fraud, Abuse, and Waste — Apparently a number of folks have not gotten the message that cheating the government and billing and collecting for services not performed will cost you a lot of money and may also land you in jail.  Not surprisingly, home health seems to be the fraudulent activity of choice.  Here are a few examples from last week:  (a) Two Detroit-area residents were arrested today on charges related to a Medicare fraud scheme in which they are alleged to have referred Medicare beneficiaries to home health care agencies in exchange for kickbacks. (b) The owner of a Miami home health care agency was arrested in connection with an $8 million health care fraud scheme involving Acclaim Home Healthcare Inc.  (c) Six South Florida residents were indicted for their alleged participation in a $6.2 million Medicare fraud scheme involving defunct home health care company Professional Medical Home Health LLC.   (d) Caremark L.L.C., a pharmacy benefit management company agreed to pay the United States $6 million to settle allegations that it knowingly failed to reimburse Medicaid for prescription drug costs paid on behalf of Medicaid beneficiaries who also were eligible for drug benefits under Caremark-administered private health plans.
  15. Canceled Health Plans — Kaiser Health News reports that “Thousands of consumers who were granted a reprieve to keep insurance plans that don’t meet the federal health law’s standards are now learning those plans will be discontinued at year’s end, and they’ll have to choose a new policy, which may cost more.”
  16. 13 Of 20 Texas Abortion Clinics Likely To Close After 5th Circuit Court of Appeals Ruling — Last August, a U.S. District Judge ruled that the purpose of part of a 2013 Texas law requiring abortion clinics to implement hospital-level upgrades at great cost was to make access to abortion difficult, and he suspended the upgrades requirement.  On October 2, the 5th Circuit Court of Appeals allowed Texas to immediately begin enforcing the required upgrades, which is expected to lead to the closure 13 out of 20 abortion facilities.
  17. Medicare Fines 2,610 Hospitals for Excessive Readmissions — Pursuant to the provisions of the Affordable Care Act, Medicare will be penalizing 2,610 hospitals for having too many patient readmissions.  This is the third year such penalties have been imposed.
  18. CMS Releases Report on FY2013 Results of RAC Audits — The purpose of the Recovery Audit Program “is to identify and correct Medicare and Medicaid improper payments through the efficient detection and collection of overpayments made on claims for health care services provided to Medicare and Medicaid beneficiaries, and the identification of underpayments to providers so that [CMS] and States can implement actions that will prevent future improper payments.”  For fiscal year 2013, “the Recovery Auditors identified and corrected $3.75 billion in improper payments. There were $3.65 billion collected in overpayments and $102.4 million in identified underpayments paid back to providers.”
  19. GAO Report to Congress:  Largest Issuers of Health Coverage Participated in Most Exchanges, and Number of Plans Available Varied — On September 29, the GAO released it Report to Congress examining “the number and types of issuers participating in both the individual and small-business exchanges beginning in 2014, as well as how this compared with issuer participation in the individual and small-group markets prior to the exchanges.”  The Report stated that “Most of the largest issuers of health coverage from 2012 participated in the exchanges that the Affordable Care Act required be established in all states in 2014. Previously, in 2012, while a large number of issuers participated in state individual and small-group markets, a small number of these participating issuers held a majority of the market share in terms of enrollment.”  The Report also found that the participating issuers represented a mix of larger, smaller, and new issuers.
  20. Philly immigrant group joins in discrimination complaint against HHS over language hurdle — This lawsuit was filed by Southeast Mutual Assistance Associations Coalition, Inc., a Philadelphia group that has helped immigrants sign up for health coverage on the federal exchange, for the purpose of blocking HHS from canceling the coverage as a result of issues from “data matching.”  According to CMS,  “A citizenship or immigration data matching issue can happen when the information reported in a consumer’s application, such as a Social Security or Permanent Resident Card number, is incomplete or different than the information the government has on file.”  Similar suits have been filed by the National Immigration Law Center and the Chicago-based Illinois Coalition for Immigrant and Refugee Rights.
Categories: Hot Topics

CMS launches database of manufacturer and GPO payments to physicians

October 3, 2014 Leave a comment

The following post will also be published today on the Akerman Health Rx blog.

The Affordable Care Act contains a provision known as the Physician Payments Sunshine Act, which requires the Centers for Medicare and Medicaid Services (“CMS”) to establish a national databank containing information on the financial relationships between physicians (which includes dentists, chiropractors, and other physician specialties) and teaching hospitals, applicable manufacturers, and group purchasing organizations (“GPOs”).  CMS launched its Open Payments website on September 30, 2014 , making its database available to the public.

The database is populated by information reported to CMS by applicable manufacturers and GPOs regarding their payments or other transfers of value to physicians and teaching hospitals.  It is important to note that this reported information specifically includes any ownership or investment interest that physicians (and their immediate family members) have in the manufacturers and GPOs.

CMS encourages physicians and teaching hospitals to register with the Open Payments website.  While registration is voluntary, the reported information is made available to registrants before being made public, and registrants are given an opportunity to dispute any reported information.  In fact, there is a mobile app (and other resources) that allows physicians, teaching hospitals, manufacturers, and GPOs to track provider and industry contact details, share information, and track payments and other transfers of value.

According to CMS and as reported, 4.4 Million payments valued at nearly $3.5 billion were made to 546,000 individual physicians and 1,360 teaching hospitals in the last five months of 2013.  The website will provide future reports on an annual basis.  Beginning in June 2015, it is expected to report twelve full months of data.

We know that the public, and in particular the press, will access the Open Payments database, and there will likely be a high level of misunderstanding and misinformation.  One cannot forget the feeding frenzy that arose when CMS released physician Medicare billing data  earlier this year.  Any physician who receives payments from a manufacturer or GPO would presumably want advance notice of any disclosure regarding payments to that physician.   Accordingly, any physician who does receive such payments should register on the Open Payments website and check the accuracy of all information reported about them, and be prepared to answer questions they may be asked.

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