09.19.09
Posted in Uncategorized at 1:00 am by chicken
Washington -- A recent addition to the growing list of flashpoints in the health system reform debate is the question of whether illegal immigrants will be able to obtain government-sponsored health insurance under the overhaul plan envisioned by lawmakers.
The reform bill pending before the House does not contain explicit provisions preventing immigrants from purchasing coverage under its proposed health insurance exchange, according to a new report commissioned by Congress and released Aug. 25. The Congressional Research Service, an arm of the Library of Congress that conducts studies for lawmakers, examined the treatment of both legal and illegal immigrants in America's Affordable Health Choices Act.
While illegal immigrants are banned from receiving government affordability credits designed to help low-income people buy coverage, they could still put up their own money to participate in the exchange. The exchange would begin operation in 2013 and include choices of private plans along with a government-sponsored, national public plan option.
The finding has given ammunition to organizations that oppose the current bill on the contention that it would force taxpayers to foot the health bill for people who are illegally in the U.S. The Pew Hispanic Center estimated in an April report that nearly 15% of the nation's 47 million uninsured are illegal immigrants. Of the nearly 12 million illegal immigrants living in the U.S. in 2008, roughly 7 million, or 59%, were uninsured.
"Case closed. Illegal aliens will be eligible to participate in the health care program offered by the House bill unless Congress acts to amend the bill," said Dan Stein, president of the Federation for American Immigration Reform. "The loopholes and omissions in the House bill are not there by accident."
59% of the nearly 12 million illegal immigrants in the U.S. are uninsured.
The question of who would qualify as a legal resident is also a point of contention. CRS said that without a provision in the bill specifying a verification procedure, a mechanism for determining coverage eligibility based on immigration status would be left to the health choices commissioner -- a new federal post that would be filled by presidential nomination if the bill becomes law.
Rep. Dean Heller (R, Nev.) offered an amendment to the legislation during the House Ways and Means Committee markup that would have required the use of existing citizenship verification tools to determine eligibility for taxpayer-funded health care benefits, but it was voted down.
"If the majority party insists on moving forward with [a] government-run health care plan, Congress should do everything in its power to curb abuse," Heller said. "Requiring citizenship verification for enrollment would ensure only citizens and legal residents receive taxpayer-funded health care."
But committee Democrats who voted against the amendment insisted that no taxpayer funds would go toward illegal immigrant coverage under the bill.
The CRS report "clarified the point that undocumented immigrants could participate in the exchange, but only to buy insurance, thus [they] are not eligible for any taxpayer-funded benefits," said Rep. Xavier Becerra (D, Calif.). Although the public plan would be government-sponsored, Democrats have said it will be sustained solely through beneficiary premiums, not federal tax revenues.
The dispute about coverage spilled over into President Obama's Sept. 9 health care address to Congress. After the president said that "the reforms I'm proposing would not apply to those who are here illegally," Rep. Joe Wilson (R, S.C.) shouted, "You lie!"
Wilson later apologized for his outburst. The White House did not specify whether Obama was referring to the issue of illegal immigrants receiving any government-sponsored insurance or just the affordability credits.
Some pro-immigration organizations said the concerns about who will receive subsidized insurance coverage are overblown.
"To fear-monger on the basis of a bill that hasn't even passed is silly," said Tamar Jacoby, president of ImmigrationWorks USA, based in Washington, D.C. "Honestly, I find it very unlikely that Congress or American voters are going to want to provide government-paid health care for illegal immigrants."
The health coverage issue for those lawfully in the U.S. is also complex. CRS concluded in its report that the House bill would require certain categories of legal residents to purchase insurance but would make them ineligible for federal assistance, regardless of income.
CRS noted that most "nonimmigrants," such as migrant workers or others who are in the U.S. for a specific purpose and time, could not receive federal affordability credits. Examples of nonimmigrants who could obtain credits include victims of human trafficking or other crimes, fiancé(e)s of U.S. citizens, and those who have had applications for legal permanent residence status pending for three years.
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Posted in Uncategorized at 1:00 am by chicken
Several states have marked Medicaid physician pay for reductions to help cover billions in budget deficits.
Ohio, Arizona and Michigan, for example, have adopted 3% to 5% fee reductions that will translate into millions in physician fee cuts. The moves could signal an end to the wave of Medicaid doctor fee increases in recent years.
The cuts might have been steeper without the $787 billion federal stimulus package, adopted in February, which included $87 billion to increase federal Medicaid matching rates by more than 6% through 2010. The federal government on average pays 57% of Medicaid costs.
But the act did not protect physician pay the way it guarded Medicaid beneficiary coverage. States accepting the additional federal funds must maintain or restore their Medicaid eligibility and enrollment standards to the same levels as they were on July 1, 2008.
"The only two areas left are provider rates or benefits, and there isn't any real money to be saved with cutting benefits," said Monica Coury, assistant director of the office of intergovernmental relations for the Arizona Health Care Cost Containment System, the state's Medicaid agency.
In July 2009, Michigan cut Medicaid doctor fees 4%.
Arizona adopted a 5% across-the-board cut to Medicaid fees for doctors, a $75 million reduction that will be fully implemented on Oct. 1. The cuts will help balance a $3 billion deficit in the state's $10 billion budget, Coury said.
Ohio adopted a 3%, $80 million cut in July that will take effect on Jan. 1, 2010. The reduction will reverse some of the gains realized through a 3% fee increase adopted last year, said Tim Maglione, the Ohio State Medical Assn.'s senior director for government relations.
The 2008 Ohio funding was not evenly distributed. Primary care physicians saw their fees climb by 7% or more, but others had their fees reduced, Maglione said. Following the same pattern, the state will try to minimize the 3% cut's impact on primary care services, said Maureen Corcoran, acting/interim Ohio Medicaid director.
Maglione said lawmakers did not unfairly target health care for reductions. The state faced an $8 billion deficit in its $51 billion budget for 2010-11. "All government services were cut dramatically," he said. Maglione predicted that the state will face additional deficits in several months because of the recession.
Maglione also expects a decrease in physician Medicaid participation, but mostly because the state's Medicaid pay has not kept pace with physicians' costs. Operating a practice in Ohio is 20% more expensive now than it was in 2000, said OSMA spokesman Jason Koma. OSMA plans a Medicaid participation survey in 2010, which would be its first in several years, Maglione said.
Michigan Gov. Jennifer Granholm implemented a 4% across-the-board cut to Medicaid fees on July 1. The state's Medicaid HMOs are expected to pass the reductions along to physicians, who are required to contract with them, said Charles J. Barone II, MD, president of the Michigan chapter of the American Academy of Pediatrics. Physician fees are negotiated with the HMOs and vary around the state. Some doctors are paid more than Medicare rates to see Medicaid patients, Dr. Barone said, while others are not as well compensated.
Granholm and the Legislature are in the midst of budget negotiations that are expected to include additional Medicaid fee cuts to address a $2.8 billion budget deficit for fiscal 2010, which begins Oct. 1. "We're all kind of holding our breath," Dr. Barone said.
Some of the proposed 2010 budgets have included 8% to 12% cuts, he said. The Legislature also has talked of imposing a tax on physicians, but Dr. Barone said lawmakers probably won't consider legislation including this provision until 2010.
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09.06.09
Posted in Uncategorized at 1:00 am by chicken
Washington -- The Obama White House has indicated it will continue the move toward more pay-for-performance in Medicare, despite mixed results for physicians in the P4P demonstrations it inherited from the previous administration.
On Aug. 17, the Centers for Medicare & Medicaid Services disclosed findings from three ongoing programs -- including first-year results from a small-practice demonstration -- and announced the start of three new value-based purchasing demonstrations.
Third-year results were revealed for the Physician Group Practice Demonstration, which is in its fifth year of operation and is slated to end March 31, 2010. Although CMS has extended the demonstration twice beyond its initial three-year limit, the agency said it does not anticipate extending the program again.
All 10 of the large physician groups participating in the program achieved benchmark performances on at least 28 of 32 quality-of-care measures, which cover diabetes, congestive heart failure, coronary artery disease, hypertension and cancer screening. Groups can receive up to 80% of the savings they generate for Medicare by reducing medical complications and hospitalizations.
But only five groups in the third year received performance bonuses, totaling $25.3 million. One group that achieved benchmark performances on all 32 measures -- Park Nicollet Health Services in St. Louis Park, Minn. -- did not receive a bonus.
The average Medicare P4P bonus for small practices was $14,000.
Four of the 10 groups that participated have not yet received a bonus despite the investments they made in quality improvement. Forsyth Medical Center in Winston-Salem, N.C., is one of them.
"We were disappointed with that, of course, because that would have helped us offset the cost of some of the programs that we created," said Nan Holland, RN, MPH. She is senior director of clinical services with Novant Medical Group, which manages Forsyth Medical Center.
Holland said the program's weakness lies with its so-called efficiency component. CMS initially had stated that the 10 physician groups could share in any savings generated. But after having already recruited the groups for the program, the agency altered the requirements. Under the revised rules, a practice would receive a payout only if savings on care for Medicare enrollees exceeded 2% in a given year, against a specified baseline.
"We're compared to other systems of organized care in the Minneapolis area, of which there are very good systems," said David Wessner, CEO of Park Nicollet Health Services, explaining why his group did not exceed the 2% threshold.
CMS changed the requirements before it launched the physician group practice program because it wanted to make sure that any Medicare savings came from the groups' direct participation in the demonstration and not from unrelated fluctuations, said John Pilotte, director of the division of payment policy demonstrations at CMS. That also was requested by the Office of Management and Budget under the Bush administration.
The upside of P4P
The late change by CMS initially caused some of the groups to question their involvement.
"We all had second thoughts," said James Rogers, MD. "It gave us all concern about how stable the project is." Dr. Rogers is medical director for the demonstration project and department chair for primary care at St. John's Health System in Springfield, Mo., which earned a bonus of about $3.1 million in the third year of the project.
But the groups felt assured about moving forward after meeting with CMS and airing their concerns, Dr. Rogers said. Some of the groups were able to build up some capital even after accounting for expenditures for quality improvement.
"We've had to invest in modest training and data reporting, but not to the extent that it would completely wipe out the bonus," said Barbara Walters, DO, senior medical director with the Dartmouth-Hitchcock Medical Center in Lebanon, N.H. The medical center earned a bonus of $3.6 million for year three. Dr. Walters said one of the best aspects of the program has been connecting with the other nine groups to share best practices.
"It's been an excellent experience," she said. "Most of us have been able to achieve the benchmarks and have at least met or exceeded targets. Every year, more of the groups have been able to demonstrate the ability to get quality care and bonus payouts."
Even practices that have not done well enough to pull down bonuses have found value in the project. "I think the organization got a lot of out of the programs we created that we think will extend well beyond the demonstration project," Forsyth Medical Center's Holland said.
New P4P programs
So far, performance bonuses have flowed only to large groups and hospitals, but that changed this year. CMS announced first-year results for the Medicare Care Management Performance Demonstration, now in its third year of operation.
Almost all of the 610 participating small and solo physician practices are being paid a total of $7.5 million for meeting quality standards through the use of health information technology. The average payment per practice was $14,000, and some practices earned as much as $62,500.
The goal of the small-practice program is to promote the use of health IT to improve the quality of care for beneficiaries with chronic conditions, CMS said. Doctors who meet clinical performance standards are eligible to receive financial rewards. In addition, the demonstration provides a bonus to practices that use a certified electronic health record. Twenty-three percent of practices were able to submit at least some of the measures from a certified EHR, CMS reported.
Hospitals in the Hospital Quality Incentive Demonstration raised their overall quality scores in five clinical areas by an average of 17.2% over four years.
CMS also announced on Aug. 17 the start of three additional Medicare value-based purchasing demonstrations. The agency will oversee two programs to evaluate the concept of gainsharing between hospitals and physicians. Another demonstration will determine if financial incentives can improve the quality of nursing home care.
"What we learn from the various Medicare demonstrations help to achieve the administration's goals of paying for high quality and efficient health care in America," said Jonathan Blum, director of CMS' Center for Medicare Management and acting director of the Center for Health Plan Choices. "Building on these findings, we will aggressively test new demonstration concepts to continue to meet these goals."
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Posted in Uncategorized at 1:00 am by chicken
Many physicians who are tuned into the health system reform debate have already heard of several of the methods being discussed for changing the way the federal government delivers care. But one Medicare delivery reform term that has recently caught the attention of Congress may be a new one to most.
The accountable care organization is one of the latest designs for managing Medicare that is gaining traction among policymakers desperate to control costs and boost quality in the system. Proponents of the concept want to see it tested along with such alternatives as patient-centered medical homes, pay-for-performance and payment bundling.
A typical Medicare ACO would include a hospital, primary care physicians, specialists and potentially other medical professionals. Services would still be billed under fee-for-service, but the organization's members would coordinate care for their shared Medicare patients with the goal of meeting and improving on quality benchmarks. Because ACO members are held jointly accountable for this care, they would share in any cost savings that stem from the quality gains.
The Medicare Payment Advisory Commission dedicated a chapter of its June report to Congress to the concept, and lawmakers have taken note. The health reform bill pending before the House includes plans for a Medicare ACO pilot program that could become permanent nationwide. Although the Senate Finance Committee has yet to unveil a bill, committee chair Max Baucus (D, Mont.) also has said the concept should be tested.
Meanwhile, the Dartmouth Institute for Health Policy and Clinical Practice and the Engelberg Center for Health Care Reform at Brookings Institution -- two leaders behind the ACO concept -- are forging ahead with their own pilot project designed to test the design in the private sector, with the hopes of adding Medicare to the mix early next year.
"This is the most likely way my colleagues and I have been able to figure out to help address variations in spending. It's much better than simply cutting prices in high-cost regions," said Elliott Fisher, MD, MPH, the Dartmouth Institute's director of population health and policy. "The ACOs are really intended to help physicians get back in the driver's seat."
An adaptable model
Medicare spends three times more per beneficiary in some regions than it does in others, with no clear evidence that the additional dollars result in higher quality of care or better outcomes, according to the Engelberg Center. The system also tends to promote high-volume and high-intensity health services, regardless of the quality of care provided and whether that care is coordinated.
The accountable care organization attempts to address these issues by linking payments to the quality and utilization of health services. Although it is a relatively new concept, it incorporates and builds on ideas from several other reform models that have been discussed for years.
An accountable care organization manages Medicare services by both physicians and hospitals.
Although the idea has some basic themes, the details still need to be worked out, said Robert Berenson, MD, a fellow at the Urban Institute in Washington, D.C. For example, some ACO models include hospitals; some don't.
Many existing groups, such as physician-hospital organizations, integrated delivery systems and independent provider associations, already give clues as to how an ACO could be structured, Dr. Fisher explained. "The goal is to be as adaptable as possible to the local circumstances of physicians."
An ACO needs to be big enough so that any cost savings can be tied to quality improvements and not year-to-year fluctuations in care, he said. That means it should have a population of at least 5,000 Medicare beneficiaries or 15,000 beneficiaries with private insurance.
Patients would retain the right to choose their physicians, so the ACO relies on patients' natural physician-selection patterns, Dr. Fisher said. Research has shown that more than 80% of patients assigned to a physician affiliated with a theoretical ACO would still be with members of that same organization a year later.
The ACO also would need a designated administrator and a formal organization that could serve as a point of contact, work with payers, monitor performance and collect any shared savings. The physicians, hospital and other ACO members would need to agree on how to divide any earned bonuses.
The division of savings issue makes some physicians uncomfortable with ACOs, said Ted Epperly, MD, president of the American Academy of Family Physicians. "We get nervous, quite frankly, with money that could potentially go through a hospital's structure and then not trickle down sufficiently to where the care is actually happening, and that's with the patient-physician relationship."
Dr. Fisher acknowledged that physicians and hospitals in some regions of the country work together on such issues much better than in other regions. In some instances, doctors and hospitals are competitors rather than collaborators.
The money that everyone could save by delivering care more efficiently could overcome this instinct, Dr. Fisher said. "The benefits from collaboration may outweigh the 'fight over the pie mentality' with which some may approach this."
Play or pay
Physicians would be better served being active participants in any proposed delivery system reforms, said Jim Hester. He's director of the Health Care Reform Commission for the Vermont State Legislature, which is working on its own accountable care organization initiative. "Something is going to change, and the ACO is a very powerful framework for trying to manage change and benefit from it instead of being punished by it."
If physicians and hospitals cannot agree to work together, the decision could be made for them. Not all proposed forms of an ACO are voluntary, with physicians given the chance to earn bonuses without having to worry about being penalized for failing to meet financial goals.
The Medicare Payment Advisory Commission in its June report explored the concept of mandatory ACOs. Under such a model, physicians and Medicare patients would be assigned to a given hospital to form an ACO. Fee-for-service payments would still be made, but part of the money would be withheld. It would only be returned -- possibly with a bonus -- if the organization meets quality and cost targets.
But some argue the mandatory path isn't politically feasible. "I don't think that's a viable model," said Dr. Berenson, who is a MedPAC member but was speaking for himself.
Glenn Hackbarth, MedPAC's chair, said at the commission's April meeting that ACOs should be voluntary, particularly because relationships will need to be redefined among health care entities that may not have worked together before. Still, "a corollary of that is that there needs to be pressure on traditional Medicare as a complementary force, and that strengthens the incentives to participate and do well," he said. The commission suggested that some restraining of fee-for-service rates might be necessary to make the ACO bonuses large enough to encourage participation.
In its Medicare reform principles, the American Medical Association has said new payment models such as ACOs should be strictly voluntary for physicians and should not be dominated by hospitals. All such models also should be tested thoroughly in a variety of practice settings, geographic locations, and among different specialties and payment populations, the AMA said.
ACO pilot set to go
For some in the private sector, the concept of the accountable care organization is ready to go beyond the theoretical stage.
The Brookings-Dartmouth ACO pilot project plans to test the model using private payers and potentially Medicaid in a variety of geographic settings and among health care entities that are at different levels of integration across the delivery system. It is expected to begin in 2010.
"The ACO looks great in concept, but we really need to show physicians and Congress how it works," Dr. Fisher said. "I would hope as [ACOs] start to succeed that this would make it even more attractive for more physicians to join."
One group -- Carilion Clinic in Roanoke, Va. -- has been chosen to participate in the ACO pilot project, and four more are expected to be added to the demonstration soon.
Carilion Clinic, a multispecialty group practice with more than 500 physicians and seven hospitals, is excited about participating, said Don Lorton, Carilion's executive vice president and chief financial officer. The ACO builds on the organization's goal to be a physician-centered organization, as opposed to a hospital system that employs physicians.
Better coordination of care can result in reduced payments in a fee-for-service payment system, Lorton said. Also, primary care physicians bear the burden of managing the care, but fee-for-service doesn't adequately pay for their extra work. The ACO concept gives Carilion the opportunity to gain some of that revenue back, he said.
Some challenges the clinic faces in setting up the ACO include working with five insurance companies to set quality goals and cost-sharing targets. Because the ACO will change the way primary care physicians and specialists manage patients, Lorton said, it also will need to improve communication and care coordination between physicians.
ACO backers in Vermont hope that one of the state's medical groups will be chosen to participate in the Brookings-Dartmouth pilot, Hester said. He noted that the state's ongoing medical home demonstration project serves as a good base from which to launch an ACO.
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Posted in Uncategorized at 1:00 am by chicken
Washington -- The Obama administration will make available nearly $1.2 billion in federal grants to create a large network of regional health information technology centers and state-based entities to support physicians and hospitals as they acquire and implement electronic health records systems that meet federal standards.
Physicians and hospitals need to have an EHR system in place that meets "meaningful use" standards if they hope to be eligible for the billions in Medicare and Medicaid bonuses available starting in 2011 through the economic stimulus package adopted earlier this year. The grants announced Aug. 20 by the Dept. of Health and Human Services and Vice President Joe Biden are designed to provide a supportive framework to help entities meet those standards, which will be proposed before the end of the year.
David Blumenthal, MD, the national health information technology coordinator, said the new money is intended to help create a national, private and secure EHR system.
"The grants are designed to help doctors and hospitals acquire electronic health records and use them in meaningful ways to improve the health of patients and reduce waste and inefficiency," he said. "They will also help states lead the way in creating the infrastructure for health information exchange, which enables information to follow patients within and across communities, wherever the information is needed to help doctors and patients make the best decisions about medical care."
Helping small practices
Under the first of the two new grant programs, nearly $600 million will be used to establish approximately 70 health IT regional extension centers. The entities will offer technical assistance, guidance and information on best practices to help physicians and hospitals more quickly become meaningful EHR users.
The regional centers will focus on helping primary care clinicians, with a particular emphasis on individual and small-group practices. Clinicians in such practices deliver the majority of primary care services but have the lowest rates of EHR adoption, and the least access to resources to help implement and use such systems, according to HHS.
Solo and small-group practices deliver the most primary care but have the lowest rates of EHR adoption.
"Expanding the use of electronic health records is fundamental to reforming our health care system," said HHS Secretary Kathleen Sebelius. "Electronic health records can help reduce medical errors, make health care more efficient and improve the quality of medical care for all Americans."
The performance of each regional center will be evaluated every two years by an HHS-appointed panel of experts. EHR industry observers are encouraged by the centers, which they say will help physicians and hospitals select certified paperless records systems that offer the best value for their needs.
"That guidance definitely needs to be there, because most providers are struggling with what they need to do, and how to do it," said Bruce Taffel, MD, vice president and chief medical officer for SharedHealth, a vendor of health information products and solutions based in Chattanooga, Tenn. "I think these extension centers will be a helpful piece of this."
The regional extension center grants will be awarded on a rolling basis, with the first awards issued in fiscal 2010, HHS said.
Focus on interoperability
The second grant program will provide more than $560 million to states starting next fiscal year through cooperative agreements to create a widespread and sustainable health information exchange.
Legal, financial and technical support is necessary to enable secure exchange of sensitive patient data across health care systems, according to HHS. The program will help fund efforts at the state level to implement directories and technical services to enable interoperability within and across states. Some health IT experts say such assistance is vital in helping physician practices become meaningful users.
Regional health IT centers will focus on helping primary care clinicians.
"I think this has tremendous potential to help improve the health IT infrastructure of the country," said Marc Probst, chief information officer with Intermountain Healthcare, a nonprofit system of hospitals and clinics based in Salt Lake City.
"A large concern is clearly the ability for people who don't have technical expertise to implement these systems," said Probst, who also is a member of the Health Information Technology Policy Committee, an advisory board established this year that makes recommendations to Dr. Blumenthal and his staff. "In just about every interview I've had with doctors, physician groups and even hospital chains, the ability to exchange data between systems was high on everyone's list."
Probst said he's very concerned about physician groups and hospitals who may not have the resources to implement an EHR that meets meaningful use standards, though he believes the policy committee's recommendations approved by Dr. Blumenthal earlier in August will be very close to what the Obama administration proposes in regulation later this year.
Dr. Blumenthal said more announcements will be made within months regarding additional grant programs to assist with EHR implementation.
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