Archive for the ‘Medicaid’ Category

Last Week’s Big Healthcare Law Stories

May 30, 2015 Leave a comment

As healthcare providers and their lawyers know, things happen fast in healthcare.  Business deals, enforcement activity, new inventions and discoveries.

Here are a few headlines from last week in no particular order:

  • OIG Mid-Year 2015 Work Plan Mid-Year Update — The OIG published its 86 page mid-year update to its 2015 Work Plan. “This edition of the Work Plan, effective as of May 2015, describes OIG audits, evaluations, and certain legal and investigative initiatives that are ongoing. In response to adjustments made to our Work Plan, this mid-year update removes items that have been completed, postponed, or canceled and includes new items that have been started since October 2014. The word “new” before a project title indicates that the project did not appear in the previous Work Plan. For each project, we include the subject, primary objective, and criteria related to the topic. At the end of each description, we provide the internal identification code for the review (if a number has been assigned) and the year in which we expect one or more reports to be issued as a result of the review. This edition also forecasts areas for which OIG anticipates planning and/or beginning work in the upcoming fiscal year and beyond. Typically, these broader areas of focus are based on the results of OIG’s risk assessments and have been identified as significant management and performance challenges facing HHS. In FY 2015 and beyond, we will continue to focus on emerging payment, eligibility, management, and information technology systems security vulnerabilities in health care reform programs, such as the health insurance marketplaces. OIG plans to add to its portfolio of work on care quality and access in Medicare and Medicaid, as well as on public health and human services programs. OIG’s examination of the appropriateness of Medicare and Medicaid payments will continue, with possible additional work on the efficiency and effectiveness of payment policies and practices in inpatient and outpatient settings, for prescription drugs, and in managed care. Other areas under consideration for new work include, for example, the integrity of the food, drug, and medical device supply chains; the security of electronic data; the use and exchange of health information technology; and emergency preparedness and response efforts.”
  • CMS Proposes New Rule for Medicaid Managed Care — “This proposed rule would modernize the Medicaid managed care regulations to reflect changes in the usage of managed care delivery systems. The proposed rule would align the rules governing Medicaid managed care with those of other major sources of coverage, including coverage through Qualified Health Plans and Medicare Advantage plans; implement statutory provisions; strengthen actuarial soundness payment provisions to promote the accountability of Medicaid managed care program rates; and promote the quality of care and strengthen efforts to reform delivery systems that serve Medicaid and CHIP beneficiaries. It would also ensure appropriate beneficiary protections and enhance policies related to program integrity. This proposed rule would also require states to establish comprehensive quality strategies for their Medicaid and CHIP programs regardless of how services are provided to beneficiaries. This proposed rule would also implement provisions of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and addresses third party liability for trauma codes.”
  • Florida Senate Tweaks Health Exchange Plan For Fast Action — “The new Senate plan would jettison an initial proposal to expand Medicaid this summer, but instead would still rely on federal money linked to President Barack Obama’s health care overhaul. Low-income Floridians would be eligible to purchase coverage through a new state-run exchange, but they would have to pay premiums and they would be required to work. The new health coverage plan would require federal approval and would not kick in until January.  It would also allow consumers who are currently getting insurance through the federal exchange to continue doing so instead being bumped to an expanded Medicaid program — something the House criticized in the initial proposal.”
  • New York Assembly Passes Universal Health Care Bill — The New York Assembly passed the New York Health Act, which is seen largely as a symbolic gesture and not likely to be passed by the Republican New York Senate.  The bill’s Economic Analysis stated “This report analyzes the economic effects of the New York Health Act …, which would establish a comprehensive, universal health insurance program for all New Yorkers. The Act would replace the current multi-payer system of employer-based insurance, individually acquired insurance, and federally sponsored programs (e.g., Medicare and Medicaid) with a single billing pipeline funded by broad-based progressively graduated assessments collected by the State and based on income and ability to pay, thereby reducing administrative bloat and monopolistic pricing and dramatically reducing the cost of health care to New Yorkers even while extending and improving the provision of care.”
  • 21st Century Cures Act: A Call to Action — “The House Energy and Commerce Committee recently approved the 21st Century Cures Act with a vote of 51-0. The nonpartisan legislation will help to modernize and personalize health care, encourage greater innovation, support research, and streamline the system to deliver better, faster cures to more patients.”
  • FTC Commissioner Calls For War On Hospital Construction Laws — Law360 reported yesterday that “Federal Trade Commissioner Maureen K. Ohlhausen on Friday urged the antitrust agency to put pressure on state legislatures around the country to scrap laws requiring state approval for the construction of new hospitals, saying the laws are ‘anti-competitive’ in nature and create barriers for new market entrants.”
  • Two Cardiologists To Pay Over $3.6 Million For Fraud — “Jasjit Walia and Preet Randhawa and their New Jersey-based cardiology practice Garden State Cardiovascular Specialists will pay the amount to resolve allegations that they submitted claims to federal insurance program Medicare for various cardiology diagnostic tests and procedures. The tests included stress tests, cardiac catheterizations and external counterpulsation, which were not medically necessary, US Attorney Paul Fishman for the District of New Jersey said.”
  • Florida’s Medical Marijuana Rules Upheld — “Florida Administrative Hearings Judge David Watkins rejected claims by an Orange County nursery that the state’s proposed rules and regulations were unfairly developed to give advantage to bigger, politically connected nurseries to win the five regional medical-marijuana-growing licenses the law allows. … Florida may now start creating a statewide medical-marijuana program that so far has only been proposed. The program, as written, allows five companies to grow low-THC marijuana, extract an oil and sell it as medicine for people who suffer from intractable epilepsy and several other debilitating conditions.”

Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care — NEJM

February 1, 2015 Leave a comment

Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care — NEJM

This article (reproduced in full below) in the New England Journal of Medicine, online January 26, 2015,  is by Sylva M. Burwell, Secretary of Health and Human Services.  It discusses the important concepts of efficiency, quality, waste, and rationing and their intersection with the delivery of healthcare.  References can be found at the online article.

* * * * * * * *

Now that the Affordable Care Act (ACA) has expanded health care coverage and made it affordable to many more Americans, we have the opportunity to shape the way care is delivered and improve the quality of care systemwide, while helping to reduce the growth of health care costs. Many efforts have already been initiated on these fronts, leveraging the ACA’s new tools. The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment models; changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and harnessing the power of information to improve care for patients.

As we work to build a health care system that delivers better care, that is smarter about how dollars are spent, and that makes people healthier, we are identifying metrics for managing and tracking our progress. A majority of Medicare fee-for-service payments already have a link to quality or value. Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients. This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare. Changes assessed by these metrics will mark our progress in the near term, and we are engaging state Medicaid programs and private payers in efforts to make further progress toward value-based payment throughout the health care system. Through Healthy People 2020 and other initiatives, we will also track outcome measures that reflect changes in Americans’ health and health care.

To drive progress, we are focusing on three strategies. The first is incentives: a major thrust of our efforts is to create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care and have the resources and flexibility they need to do so. The ACA creates a number of new institutions and payment arrangements intended to drive the health care system in this direction. These include alternative payment models such as ACOs, advanced primary care medical-home models, new models of bundling payments for episodes of care, and demonstration projects in integrated care for beneficiaries dually eligible for Medicare and Medicaid.

Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions. Three years ago, Medicare made almost no payments through these alternative payment models,1 but today such payments represent approximately 20% of Medicare payments to providers, and as noted above, we aim to increase this percentage. As part of this work, we also recognize the need to continue to reach consensus on the quality measures used and address issues related to risk adjustment in these new models.

Second, improving the way care is delivered is central to our reform efforts. We have put in place policies to encourage greater integration within practice sites, greater coordination among providers, and greater attention to population health. Through the Partnership for Patients, we have engaged U.S. hospitals in learning networks to focus on high-priority risks to patient safety and have already seen significant improvement. There is now a national program to reduce hospital readmissions within 30 days after discharge, which encourages hospitals to improve transitional care and coordinate more effectively with ambulatory care providers. Readmission rates are decreasing nationwide.2 Through the Transforming Clinical Practice Initiative, we will invest up to $800 million in providing hands-on support to 150,000 physicians and other clinicians for developing the skills and tools needed to improve care delivery and transition to alternative payment models. New Medicaid health homes, patient-centered medical homes, and efforts to reorganize care for people eligible for both Medicare and Medicaid are all designed to foster greater integration and coordination.

Third, we aim to accelerate the availability of information to guide decision making. The Obama administration has led a major initiative in health information technology (IT), focusing on the adoption of electronic health records (EHRs) and their meaningful use as a central avenue for transforming care. The proportion of U.S. physicians using EHRs increased from 18% to 78% between 2001 and 2013, and 94% of hospitals now report use of certified EHRs.3 Ongoing efforts will advance interoperability through the alignment of health IT standards and practices with payment policy so that patients’ records are available when needed at the point of care to permit informed clinical decisions to be made in a timely fashion.  HHS has made a commitment to enhancing transparency in the health care market. For example, the Medicare website enables consumers to compare data on the costs and charges for hundreds of inpatient, outpatient, and physician services. Information is available on the quality of hospitals, physicians, nursing homes, and other providers, enabling consumers to make better-informed choices when selecting providers and health plans.

The ACA established the Patient-Centered Outcomes Research Institute (PCORI), dedicated to generating information that can guide doctors, other caregivers, and patients as they address important clinical decisions; PCORI is working with the Agency for Healthcare Research and Quality to disseminate this information. In the years ahead, the research findings from PCORI, disseminated in part through EHRs, can bring critical clinical information to providers and patients when they need it most, at the point of care.

Although we have much to celebrate regarding increased access and quality and reduced cost growth, much of the hard work of improving our health care system lies ahead of us. Care delivered in hospitals was much safer in 2013 than it was in 2010: there were 1.3 million fewer adverse events between 2011 and 2013 than there would have been if the rate of such events had remained unchanged, and an estimated 50,000 deaths were averted. Still, far too many hospitalized patients — nearly 1 in 10 — have adverse events while hospitalized, and many people do not receive care that they should receive, while others receive care that does not benefit them. Growth of health care spending is at historic lows: Medicare spending per beneficiary increased by approximately 2% per year from 2010 to 2014 — a rate far below both historical averages and the growth rate of the gross domestic product.4 Survey data show that more than 7 in 10 people who signed up for insurance in the new health insurance marketplace last year say the quality of their coverage is excellent or good.5 However, it will take additional effort to sustain and augment the positive changes we have seen so far.

We are dedicated to using incentives for higher-value care, fostering greater integration and coordination of care and attention to population health, and providing access to information that can enable clinicians and patients to make better-informed choices. We believe that, by working in partnership across the public and private sectors, we can accelerate these improvements and integrate them into the fabric of the U.S. health system.

Ohio Decides to Expand Medicaid

October 27, 2013 Leave a comment

As reported in “Action of Ohio Controlling Board on Medicaid Expansion” posted on Bill of Health, a blog sponsored by the Petrie-Flom Center at Harvard Law School:

On Monday, October 22, at the urging of Governor Kasich, the  Controlling Board of the Ohio Legislature voted 5-2 to accept $2.5  billion in federal funding to expand Medicaid in the State of Ohio.  Under the laws of Ohio this action was valid.



Poorest of the poor left out of Affordable Care Act’s health insurance expansion

October 13, 2013 Leave a comment

Because North Carolina rejected the Medicaid expansion earlier this year, the state’s poorest residents will go without insurance despite the national law that was intended to slash the number of uninsured.

This is another example of the short-sightedness (or just plain meanness — it’s hard to know which) of conservative state legislatures that decided taking a stand against Obamacare was more important than the health of its citizens.  The Presdient and the ACA will be blamed by the campaign of misinformation from the Tea Party, but this is their fault, not the President’s and certainly not the law’s.

See on

See more on Scoop.itChanging Healthcare for the Better

How Health Care Reform is Supposed to be Working

October 11, 2013 1 comment

The RAND Corporation has published a study, “Effects of the Affordable Care Act on Consumer Health Care Spending and Risk of Catastrophic Health Costs.”

RAND provides the following summary of the study:

This study examines the likely effects of the Affordable Care Act (ACA) on average annual consumer health care spending and the risk of catastrophic medical costs for the United States overall and in two large states that have decided not to expand their Medicaid programs (Texas and Florida). The ACA will have varied impacts on individuals’ and families’ spending on health care, depending on income level and on estimated 2016 insurance status without the ACA. The authors find that average out-of-pocket spending is expected to decrease for all groups considered in the analysis, although decreases in out-of-pocket spending will be largest for those who would otherwise be uninsured. People who would otherwise be uninsured who transition to the individual market under the ACA will have higher total health care spending on average after implementation of the ACA because they will now incur the cost of health insurance premiums. The authors also find that risk of catastrophic health care spending will decrease for individuals of all income levels for the insurance transitions considered; decreases will be greatest for those at the lowest income levels. Case studies found that in Texas and Florida, Medicaid expansion would substantially reduce out-of-pocket and total health care spending for those with incomes below 100 percent of the federal poverty level, compared with a scenario in which the ACA is implemented without Medicaid expansion. Expansion would reduce the risk of high medical spending for those covered under Medicaid who would remain uninsured without expansion.

You can read the Study online or download a copy here.

Florida Cares About Healthcare … Not

September 20, 2013 Leave a comment

I have been very remiss about posting for the last several weeks.

Being a Floridian is very depressing.  Florida’s elected and administrative leaders have done everything they can to misinform Floridians about Obamacare, to keep the needy from accessing care, to prevent the uninsured from being able to purchase affordable health insurance, and to force healthcare providers to provide unreimbursed care.

Earlier today, Health News Florida reported on how politics over healthcare reform has become more important than either healthcare or meaningful reform.

  • The New York Times reported on Tuesday that “Gov. Rick Scott and the Republican-dominated [Florida] Legislature have made it more difficult for Floridians to obtain the cheapest insurance rates under the exchange and to get help from specially trained outreach counselors.”
  • The Miami Herald reported also on Tuesday that HHS Secretary Kathleen Sebelius, stated that Florida officials are “keeping information from people” in a political effort to foil the effort to enroll Floridians for health insurance.
  • Florida AG Pam Bondi and CFO Jeff Atwater have also joined in the campaign of misinformation and deceit.

The list of wasted Florida tax dollars and loss of Federal funding in trying to impede Obamacare was reported by Health News Florida earlier this week.  Florida’s list of shame includes the following:

  • Leading the court challenge on the constitutionality of Obamacare in 2010 soon after it was signed into law.   Attorney General Pam Bondi made it one of her high-profile issues, becoming a regular guest on Fox News to attack it.
  • After the Supreme Court ruled the law was constitutional, the Florida Legislature told state agencies not to implement it because lawmakers felt sure the Republican party Presidential candidate, Mitt Romney, would win the election in 2012 and repeal the law.
  • After Romney lost the election, governor and legislature pressured the agencies not to apply for grants related to the law; some agencies had to give back grants they had already been awarded.
  • The Legislature this year voted against Florida having its own electronic marketplace for health-plan shopping, even though the state had already spent five years and several million dollars building an online shopping site, Florida Health Choices, that has yet to be used.
  • After months of hearings and negotiations, the Florida Senate came up with a compromise plan on Medicaid expansion that would accomplish several things — reduce the number of uninsured Floridians by about 1 million by using federal funds,  save millions of state dollars now being spent on the uninsured, and continue privatization of the Medicaid program, already well under way.  But the House said no.
  • The Legislature voted to strip the Insurance Commissioner’s authority to regulate health premiums for two years.
  • Insurance Commissioner Kevin McCarty issued a report that predicted health premiums in Florida’s  individual market would soar 30 to 40 percent, thereby producing scandalous headlines. Later, others would note that the figure failed to make adjustments for the tax credits most of those shopping in that market would qualify for. He also failed to mention that the sector he was describing accounts for only 5 percent of policies.

It’s all really quite pathetic and disgusting.  It’s time to vote the bastards out.

Physician Payment Sunshine Act

July 27, 2013 Leave a comment

The vilification of physicians continues …

The Physician Payment Sunshine Act has been around for a while now, but things are getting ready to heat up.  On August 1, the federal regulations implementing the Physician Payment Sunshine Act go into effect.

The regulations were finalized last February, to “implement the requirements in section 6002 of the Affordable Care Act … . That provision requires applicable manufacturers of drugs, devices, biologicals, or medical supplies covered under [Medicare or Medicaid or CHIP] to report annually to the Secretary certain payments or other transfers of value to physicians and teaching hospitals. [The Act] also requires applicable manufacturers and applicable group purchasing organizations to report certain information regarding the ownership or investment interests held by physicians or the immediate family members of physicians in such entities.”

Medical Economics published a very good summary of the Sunshine Act, “Sunshine Act: 7 things you need to know.”  Manufacturers and GPOs on August 1 will start gathering data on physicians with whom they have made a specified payment or other transfers of value or who have investment or ownership interests in the manufacturers or GPOs.  The nearly 80 triple-columned pages of regulations define the various terms and explain how the data is to be gathered and reported.  The data will be reported to CMS electronically by March 31, 2014 and will be available online to patients and others.

In a related story, Medical Economics reported yesterday that there is now an app for physicians to track reports made regarding them pursuant to the Act.

New direction for Medicaid in Alabama

June 30, 2013 Leave a comment

About 120,000 Medicaid patients in the Shoals and Tennessee Valley will receive most of their health care from a network of willing providers within a 10-county region beginning in late 2016

The new direction for the state agency is part of a plan legislators approved earlier this year to control Medicaid’s ballooning costs.

State leaders plan to turn Medicaid from its current fee-for-service model to a managed care approach, beginning in fiscal 2017.

To make the transition, Medicaid officials are splitting the state into five areas where Regional Care Organizations — largely run by healthcare providers — will operate.

“The (Regional Care Organizations) came about because we’ve been on a fee-for-service type system with Medicaid, which doesn’t encourage providers to maximize efficiencies,” said Rep. Ed Henry, R-Hartselle, one of several lawmakers on Gov. Robert Bentley’s Medicaid study commission.

“This reform measure is to try to put efficiencies in Medicaid,” he said. “We pay providers a set amount per patient and if they deliver that care for cheaper, they make money. If they don’t, they lose money.”

David Spillers, CEO of Huntsville Hospital, said the regional organizations, or RCOs, will be a complete change in how Medicaid providers are reimbursed. The Huntsville Hospital system includes 12 medical facilities in north Alabama, including Helen Keller Hospital in Sheffield.

The Medicaid crisis in Alabama (and the other 49 states) was not caused by Obamacare.  But for the first time, there is a national debate on how to make healthcare more effective AND more cost-efficient.  Obamacare has forced legislatures to face the horrible problems of increasing healthcare costs and poor healthcare and to solve those problems in someway other than to ignore them.

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Health Affairs: For States That Opt Out Of Medicaid Expansion: 3.6 Million Fewer Insured And $8.4 Billion Less In Federal Payments

June 9, 2013 Leave a comment

According to a study published in the June 2013 issue of Health Affairs:

[F]ourteen governors have announced that their states will not expand their Medicaid programs. We used the RAND COMPARE microsimulation to analyze how opting out of Medicaid expansion would affect coverage and spending, and whether alternative policy options—such as partial expansion of Medicaid—could cover as many people at lower costs to states. With fourteen states opting out, we estimate that 3.6 million fewer people would be insured, federal transfer payments to those states could fall by $8.4 billion, and state spending on uncompensated care could increase by $1 billion in 2016, compared to what would be expected if all states participated in the expansion. These effects were only partially mitigated by alternative options we considered. We conclude that in terms of coverage, cost, and federal payments, states would do best to expand Medicaid.

Florida Medicaid Managed Care Receives Green Light From HHS

February 8, 2013 Leave a comment


From Akerman’s Health Law Rx Blog:


Florida has been working on a plan to shift the state’s Medicaid population into managed care for nearly two years – ever since the Florida Legislature directed the change in 2011. On Monday the state received the approval it needed from the federal government.

By letter dated February 1, 2013, the U.S. Department of Health and Human Services granted Florida’s request to waive certain provisions of the Social Security Act, allowing the state to transfer some Medicaid recipients from the traditional fee-for-service program into a Medicaid managed care plan for individuals needing long-term care.

The federal waiver is limited to the state’s Medicaid Long-Term Care Managed Care recipients.  It will allow up to 36,795 Medicaid recipients to receive long-term care services from health maintenance organizations (“HMOs”) or provider services networks (“PSNs”) in the recipient’s local area.  Such a transition would include access to services including adult day health care and case management, instead of more costly nursing home care.  The waiver goes into effect on July 1, 2013, ahead of the state implementation deadline of October 1, 2013.  On January 15, the Florida Agency for Health Care Administration (“AHCA”) posted notices of intent to award Medicaid Long-Term Care Managed Care contracts to PSN American Eldercare and HMOs including UnitedHealthcare of Florida and Sunshine State Health Plan.

A second waiver request is pending with HHS.  If granted, it will allow Florida to shift the majority of remaining fee-for-service Medicaid recipients into the Managed Medical Assistance program via an HMO or PSN in the recipient’s area.  On December 28, 2012, AHCA issued the invitations to negotiate seeking managed care organizations to provide Mandatory Managed Medical Assistance to Medicaid recipients in Florida.  It is anticipated that AHCA will post the notice of intent to award these contracts on September 16, 2013.  If the second waiver request has been granted by this time, the anticipated contract execution date is December 31, 2013.

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