HUMANA: Exits Medicare Part C Plan Markets

By Staff Reporters

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Humana Plans to Leave Some Medicare Advantage Markets in 2025

Humana expects to exit Medicare Advantage (MA) markets in 2025, company executives told investors. The company reported its first quarter earnings April 24th. Humana posted $741 million in net income in the first quarter of 2024, beating investor expectations, but pulled its 2025 earnings guidance. 

On an April 24th 2024 call with investors, Humana executives said it will look to pull back benefits and exit some markets, as CMS continues phasing in risk adjustment changes. CMS published its final MA rate notice for 2025 earlier this month. The agency slightly cut benchmark payments and continued phasing in coding changes. Humana previously said the agency’s rates were lower than its expectations.

Other payers have signaled they will likely cut benefits to accommodate the rate notice. 

Source: Rylee Wilson, Becker’s Payer Issues [4/25/24]

CITE: https://www.r2library.com/Resource

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DAILY UPDATE: Anti-Competitive Practices in Healthcare and the NASDAQ and S&P 500 Losing Streak!

HAPPY EARTH DAY

By Staff Reporters

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Feds Open Online Portal for Reporting AntiCompetitive Practices in Healthcare

Federal agencies want to hear from the public about monopolistic and anticompetitive behavior within the healthcare industry. Last Thursday, the Federal Trade Commission (FTC), the Department of Justice (DOJ) and the Department of Health and Human Services (HHS) unveiled HealthyCompetition.gov, an online portal where anyone can submit a healthcare competition complaint for potential investigation.

These submissions, the agencies said, can help the agencies ensure healthcare organizations provide quality care and pay their employees a fair wage.

Source: Dave Muoio, Fierce Healthcare [4/18/24]

CITE: https://www.r2library.com/Resource

The S&P 500 just had its worst week in more than a year, and the NASDAQ is on a four-week losing streak. Blame skepticism that AI will meaningfully boost profits: Since the NASDAQ peaked last month, the largest US tech companies have lost more than $930 billion in market value. NVIDIA alone lost $212 billion in value on Friday, its biggest plunge since March 2020.

PS: Exxon Mobil is worth more than Tesla for the first time in more than a year.

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DAILY UPDATE: Medicaid and Government Employee Health Insurance Changes as Stocks Tank

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Texas Governor Greg Abbott has issued a sharp warning about proposed changes to Medicaid, claiming they could “strip millions of Americans” from access to healthcare. In February 2023, the Centers for Medicare & Medicaid Services (CMS) issued a new proposed rule that would change long-standing practices for how states fund the non-federal share of Medicaid payments. In particular, the CMS is pushing for greater oversight of how states use of healthcare provider taxes to help fund their programs.

CITE: https://tinyurl.com/2h47urt5

Democratic lawmakers Sen. Richard Blumenthal and Rep. Andy Kim have partnered up with Republican Rep. Jen Kiggans to introduce legislation aiming to give army reservists and members of the National Guard that also work for the federal government options on the type of health care plans they can receive. The bill, which could impact thousands of federal employees that are also in the U.S. Army, plans to give this group of Americans the ability to decide whether they want military or civilian health care. The lawmakers said in a shared statement that their proposal will fix current regulations that limit service members who also work for the government to enroll in the cheaper Tricare Reserve Select (TRS) health plan when they also qualify for federal health plans.

CITE: https://tinyurl.com/tj8smmes

Stocks tanked last Friday after the big banks reported underwhelming earnings and the sheen from the Magnificent Seven’s AI-driven surge earlier this week wore off. Meanwhile, oil prices continue to rise near six-month highs as concern grows over geopolitical tensions in the Middle East. The tech sector was highlighted in this market, particularly due to the exceptional performance of a group of mega-cap tech giants last year nicknamed the “Magnificent Seven.” This elite group includes Apple (AAPL), Amazon (AMZN), Alphabet (GOOGL), Meta Platforms (META), Microsoft (MSFT), Nvidia (NVDA) and Tesla (TSLA).

CITE: https://www.r2library.com/Resource

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The Medicare Cost-Control Efficiency Paradox

Essay on the Eight-Hundred Pound Gorilla in the Medical Treatment Room

By Dr. David E. Marcinko MBA MEd CMP

[Editor-in-Chief]

According to economist Austin Frakt PhD, and others, there is a school of thought that says Congress is incapable of controlling costs in the Medicare and Medicaid System [CMS].

And, then there is the reality known by all practicing medical professionals regardless of specialty orientation or degree designation. That is to say, CMS really can control healthcare costs and with great ferocity and efficiency, and to non-public sectors as well …. PARADOXICAL?

On Getting What You Wish For

Blogger Ezra Klein opines that one of the dirty little secrets of the health-care system is that Medicare has done a much better job controlling costs than private health insurers.

http://voices.washingtonpost.com/ezra-klein/2010/11/what_happens_when_medicare_con.html

A Forehead-Palm Moment

Of course, we doctors know that the real problem is that Medicare seemingly [think Seinfeld’s character George Costanza] controls costs all too well; but not really. It is just that CMS pays doctors too little and thus it appears costs are controlled. What really is happening is that physician fees are being reduced carte’ blanche.

Nevertheless, and regardless of semantics, CMS will never control costs much more efficiently than private insurance companies or doctors will simply abandon Medicare for related payment models like direct reimbursement or concierge medicine. This is happening right now. Physicians, osteopaths and podiatrists etc, are opting out of Medicare in increasingly large numbers. In a world where there’s only Medicare and Medicare to control costs, doctors can either take the pay cut or stop seeing patients, and stop being doctors. “Taking what they are given – because they’re working for a livin.”

So sorry that this seems like a forehead-palm moment for Ezra, but not for healthcare practitioners or the ME-P!

Too Much Demand Elsewhere

And, as we see from other countries, many young bright folks want to be doctors, even if being a doctor doesn’t make one particularly wealthy [high demand and high eventual supply produces lower provider costs in the long term?]. Think medical tourism.

Not so much the case anymore in this country [lower demand and lower eventual supply produces higher reimbursement costs to the doctor survivors in the very long term?].

Our Domestic World

But, we are not elsewhere. In fact, in our present domestic healthcare ecosystem, when Medicare decides to control costs, many doctors can simply stop accepting Medicare patients, and the politicians will lose their jobs. One political party then declares that Medicare is rationing and will hurt senior citizens. The other party capitulates and pays MDs more [SGR]. Then, the federal budget looks bad as it does now. The circle is complete when one party asserts that Medicare actually can’t contain costs but the private insurance companies will.  It all fails, in an unending circular Boolean-like loop of illogic.

Listen Up!

So, listen up AARP, politicians, CMS and seniors as I admonish you to be careful what you wish for [medical cost controls]. It might just come true. As Ezra rightly says; rinse, repeat – rinse, repeat – ad nausea. You simply can’t have it both ways.  You either choose to spend less and offend certain cohorts, or spend more and offend different factions.  Either way, you’re going to piss someone off. A good healthcare reimbursement system would try to make that decision rationally [a-politically]. But, at least it would make an economics driven decision; wouldn’t it?

Assessment

Is CMS really the eight hundred pound cost-controlled gorilla in the increasingly large Medicare treatment room? Why or why not? Now, relative to the ACA of 2010, please read: The Case for Public Plan Choice in National Health Reform [Key to Cost Control and Quality Coverage], by Jacob S. Hacker, PhD. Link: Jacob Hacker Public Plan Choice

Conclusion

And so, your thoughts and comments on this ME-P are appreciated. Do we have a Medicare cost control efficiency paradox? Or, are the economists just reveling in the publication banal? Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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PHYSICIAN PAYMENTS: Drug and Device Makers

By Staff Reporters

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Physicians Received $12 Billion from Drug & Device Makers in Less Than 10 Years

A review of the federal Open Payments database found that the pharmaceutical and medical device industry paid physicians $12.1 billion over nearly a decade. Almost two thirds of eligible physicians — 826,313 doctors — received a payment from a drug or device maker from 2013 to 2022, according to a study published online in JAMA on March 28th. Overall, the median payment was $48 per physician.

CITE: https://www.r2library.com/Resource

Orthopedists received the largest amount of payments in aggregate, $1.3 billion, followed by neurologists and psychiatrists at $1.2 billion, and cardiologists at $1.29 billion. To find out what any physician was paid, click here.

Source: Alicia Ault, MD Edge [4/3/24]

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CMS Announces Updates to ACO REACH Model

By Health Capital Consultants, LLC

CMS Announces Updates to ACO REACH Model

On August 14, 2023, the Centers for Medicare and Medicaid Services (CMS) announced updates to their Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) model.

CITE: https://www.r2library.com/Resource

In response to feedback from stakeholders, starting in performance year (PY) 2024, the agency expects to increase the predictability for the model and further advance health equity. Only in its first PY, ACO REACH is a revision and replacement of the Global and Professional Direct Contracting (GPDC) model and the Geographic Direct Contracting (Geo Model) model, a subset of the GPDC model. This Health Capital Topics article will discuss the updates to the ACO REACH model and its implications for existing accountable care organizations (ACOs). (Read more…)

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PODCAST: Medicare CMS Innovation Center

By Eric Bricker MD

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CMS Emergency Funds for Doctors Affected by Change Healthcare Hack

By Staff Reporters

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Federal health officials said they would offer emergency funding to physicians, physical therapists, and other professionals that provide outpatient healthcare, following a cyberattack that crippled the nation’s largest processor of medical claims and left many organizations in financial distress. The Centers for Medicare and Medicaid Services also announced that it would make advance payments available to suppliers that bill through Medicare Part B, which serves a wide array of healthcare organizations.

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Officials had previously announced a similar program to make emergency payments available for hospitals that had been ensnared by the February 21st hack of Change Healthcare, a unit of UnitedHealth Group, and have struggled to get paid for more than two weeks. The emergency funds represent upfront payments made to healthcare providers and suppliers based on their expected future claims.

CITE: https://www.r2library.com/Resource/Title/082610254

Source: Dan Diamond, Washington Post [3/9/24]

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CONGRESS: Increases 2024 Medicare Physician Pay

By Health Capital Consultants, LLC

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On March 9th, 2024, President Biden signed into law a $460 billion spending package to continue funding the federal government for the remainder of the 2024 fiscal year. Contained within the spending package was legislation to cut in half the 2024 Medicare physician payment update of approximately -3.4%.

This Health Capital Topics article discusses the payment update, other healthcare provisions contained in the bipartisan spending bills, and responses from stakeholders. (Read more…)

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DAILY UPDATE: Independent Pharmacies Struggle as Stocks Hit New Highs

By Staff Reporters

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Independent pharmacies have struggled in recent years to stay open—and new financial constraints may mean a record number of pharmacy closures in 2024. And, nearly a third of independent pharmacies are at risk of going out of business due in part to a new rule from the Centers for Medicare and Medicaid Services (CMS) that results in lower prescription reimbursements, according to the National Community Pharmacists Association (NCPA), a trade group that represents more than 19,400 US pharmacies.

“This is an emergency,” NCPA CEO B. Douglas Hoey said in a statement. “If Congress fails to act again, thousands of local pharmacies could be closed within months and millions of patients could be stranded without a pharmacy.” The CMS rule, which went into effect on January 1st, requires payers and pharmacy benefit managers (PBMs) to apply what’s called direct and indirect remuneration (DIR) fees at the time a patient picks up a prescription.

CITE: https://www.r2library.com/Resource

Here’s where the major benchmarks ended:

  • The S&P 500 index added 44.91 points (0.9%) to 5,248.49; the Dow Jones Industrial Average climbed 477.75 points (1.2%) to 39,760.08; the NASDAQ Composite added 83.82 points (0.5%) to 16,399.52. 
  • The 10-year Treasury note yield fell four basis points to just under 4.2%.
  • The CBOE Volatility Index® (VIX) dropped 0.48 to 12.76.

In addition to utility stocks, real estate, industrials, and materials were the strongest sectors. Information technology and communications were the weakest but found late-day strength to finish higher.

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PODCAST: Risk Adjustment in Medicare Advantage [Part C] Plans

CMS PAYMENTS TO INSURANCE PLANS

By Eric Bricker MD

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ACOs: Participation Up in 2024

By Health Capital Consultants, LLC

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On January 29, 2024, the Centers for Medicare and Medicaid Services (CMS) announced that Performance Year 2024 participation increased in their various accountable care organization (ACO) initiatives. Specifically, 50 new ACOs joined the Medicare Shared Savings Program (MSSP), and 71 ACOs renewed their contracts, bringing the total participation in the MSSP to 480 ACOs.

Additionally, 245 organizations chose to continue participation in two other CMS models – the ACO Realizing Equity, Access, and Community Health (REACH) Model and the Kidney Care Choice (KCC) Model.

CITE: https://www.r2library.com/Resource

This Health Capital Topics article reviews the CMS report and implications for CMS’s ACO initiatives. (Read more…) 

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VINTAGE: Pay-4-Performance Healthcare

Pay for Performance Initiatives

[By Staff Writers]

Of course, consumer directed healthcare trends and fee transparency increasingly mandate physician economic accountability, such as in the P4P initiatives, but CMS may also begin profiling physicians and targeting those it deems inefficient sometime next year, as well.

In May 2007, Herbert Kuhn, acting deputy administrator of CMS, told a House subcommittee that the agency will have the data and computer capacity available to do tracking as soon as mid-2008.

To monitor efficiency, CMS would compare levels of tests physicians order for certain types of patients to tests ordered by other doctors who achieve similar outcomes. The agency would then contact the physicians whose testing patterns seem to be out of line. No doubt, the effects on private pay-for-performance [P4P] initiatives is obvious.  Kuhn told the subcommittee that his largest concern was figuring out how to use the data to help physicians grow more efficient.

Assessment

To date, the agency hasn’t established plans to link efficiency measures with reimbursement changes. If it wants to do so, Congress would probably have to enact new legislation, according to several policymakers.

Conclusion

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HEALTHCARE: Spending Grew in 2022

By Health Capital Consultants, LLC

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On December 13, 2023, the Centers for Medicare & Medicaid Services (CMS) released its annual report on healthcare spending in the U.S., highlighting the growth in private insurance and Medicaid spending in 2022, which was offset by the declines in supplemental federal funding as a result of the COVID-19 pandemic.

CITE: https://www.r2library.com/Resource/Title/082610254

This Health Capital Topics article reviews the notable healthcare spending findings in CMS’s report. (Read more…) 

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MEDICARE [dis] ADVANTAGE Plans?

By Staff Reporters

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Leading hospital trade groups are accusing some Medicare Advantage plans, including giant UnitedHealthcare, of flaunting coverage requirements recently codified by CMS. The American Hospital Association is now petitioning the Biden administration to crack down.


However … the Medicare Advantage market is booming but investment in cancer care continues to lag.

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MPFS Final Rule Cuts Physician Payments

Medicare Physician Fee Schedule

By Health Capital Consultants

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DEFINITION: The Centers for Medicare and Medicaid Services (CMS) uses the Medicare Physician Fee Schedule (MPFS) to reimburse physician services. The MPFS is funded by Part B and is composed of resource costs associated with physician work, practice expense and professional liability insurance.

Under the MPFS, each of these three elements is assigned a Relative Value Unit (RVU) for each Current Procedural Terminology (CPT®) code. These RVUs are then adjusted based on the Geographical Practice Cost Index associated with various geographic areas for different medical costs and wage differentials. The conversion factor is the national dollar amount that is multiplied by the total geographically adjusted RVU to determine the Medicare-allowed payment amount for a particular physician service.

CITE: https://www.r2library.com/Resource

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MPFS Final Rule Cuts Physician Payments

On November 2nd, 2023, the Centers for Medicare & Medicaid Services (CMS) released its finalized Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2024. While the finalized fee schedule cuts payments to physicians, there are a number of other (more positive) provisions in the final rule.

This Health Capital Topics article explores the various changes and updates included in the MPFS final rule. (Read more…)

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“BREAKING NEWS” Cigna and Humana to Merge?

By Staff Reporters

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Cigna and Humana are in talks for a combination that would create a new powerhouse in the health-insurance industry. The companies are discussing a stock-and-cash deal that could be finalized by the end of the year, assuming the talks don’t fall apart.

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A combination of the managed-care providers would be huge, given Cigna’s market value Wednesday morning of about $83 billion and Humana’s of roughly $62 billion.

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Cigna and Humana previously explored merging in 2015, but Humana instead struck a deal with another rival, Aetna, that was blocked by a judge on antitrust grounds, leaving Aetna to be scooped up by CVS in 2018. Another deal that would have combined Cigna with Anthem, now known as Elevance Health, also died after an adverse antitrust ruling.

CITE: https://www.r2library.com/Resource

Editor’s Note: Medicare Advantage plans are pretty popular with both lawmakers and ordinary Americans — they now enroll about 31 million people, representing just over half of everyone in Medicare, by KFF’s count. Across the country, doctors are grumbling about claim denials and onerous pre-approval requirements by Medicare Advantage plans. Some hospitals and physician practices are so fed up they’re refusing to accept the plans — even big ones like those offered by United Healthcare, Cigna and Humana.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

And, just last week, the industry’s largest lobbying group, the American Hospital Association, fired off a letter to the Centers for Medicare and Medicaid Services warning that some insurers seem intent on circumventing new rules put in place by the Biden administration aimed at reining in some prior authorization and claim denials.

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HEALTHCARE: Business News

By Staff Reporters

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House Democrats want CMS to better monitor Medicare Advantage plans’ use of AI tools to ensure they don’t allow an unusually high level of restrictive and repeated denials.


Kaiser Permanente continues to rebound from a rough 2022 and pulled in $239 million in net income in Q3. That marks a dramatic turnaround from the $1.5 billion net loss the integrated system had seen a year prior.

CITE: https://www.r2library.com/Resource


And … during the Milken Institute’s Future of Health Summit Monday, former HHS Secretary Alex Azar and current department chief Xavier Becerra sparred over the Biden administration’s approach to negotiating Medicare drug prices.

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Finally, family physicians utilizing value-based payment (VBP) models reported burnout relief in a study from EHR company Elation Health and the American Academy of Family Physicians. Burnout among providers decreased once practices passed a threshold of 75% financial investment in VBP models.

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Case Model Illustration of a Six Sigma Healthcare Pioneer

The Mount Carmel Health System

By Mark Matthews MD

A “Scrubbed” True Illustration

One of the earliest healthcare adopters of Six Sigma was the Mount Carmel Health System in Columbus, Ohio.

The organization was barely breaking even in the summer of 2000 when competition from surrounding providers made things worse. Employee layoffs added fuel to an already all-time low employee morale.

The CEO

Chief Executive Officer Joe Calvaruso was determined to stem the bleeding, break the cycle of poor financial performance and return the hospital system to profitability.  He sought the potential benefits of Six Sigma and began a full deployment of its methodology. The plan was a bold move, as the organization ensured that no one would be terminated as a result of a Six Sigma project having eliminated his or her previous duties. These employees would be offered an alternative position in a different department. Moreover, top personnel were asked to leave their current positions to be trained and work full time as Six Sigma expert practitioners who would oversee project deployment while their positions were backfilled.

Assessment

The Six Sigma deployment was the right decision. More than 50 projects were initiated with significant success. An example of an early Mount Carmel success story is the dramatic improvement in their Medicare + Choice product reimbursements, previously written off as uncollectible accounts. These accounts were often denied by HCFA due to coding of those patients as “working aged.”

Since the treatment process status often changed in these patients, HCFA often rejected claims or lessened reimbursement amounts, effectively making coding a difficult and elusive problem. The employment of the Six Sigma process fixed the problem, resulting in a real gain of $857,000 to the organization. The spillover of this methodology to other coding parameters also has dramatically boosted revenue collection.

A Glimpse of Lean Medical Management Tools and Techniques

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

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CMS: Proposes Fee Schedule Payment Cuts to Doctors

By Staff Reporters

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According to Paige Minemyer of Fierce Healthcare, the Joe Biden administration is proposing cuts to physician payments in its annual fee schedule, and doctors are not happy. Major industry groups have roundly called for Congress to step in to prevent the Medicare reimbursement changes from going through. Last week, the Centers for Medicare & Medicaid Services (CMS) proposed a 3.34% cut to the fee schedule’s conversion factor, which is used to calculate Medicare payouts to docs.

More: https://www.ama-assn.org/practice-management/medicare-medicaid/proposed-336-medicare-pay-cut-shows-why-overhaul-badly-needed

In a statement, the American Medical Group Association (AMGA) said that Medicare payments already fail to keep up with “the increasing cost of delivering healthcare,” and further cuts would only exacerbate that problem. “AMGA members cannot absorb this proposed payment cut,” said AMGA President and CEO Jerry Penso, MD.

BIO: https://www.amga.org/about-amga/amga-difference/board-of-directors/penso/

“Their expenses are continuing to increase, and Congress needs to act to ensure Medicare’s reimbursement reflects the cost of delivering high-quality care to patients.” 

CITE: https://www.r2library.com/Resource

Source: Paige Minemyer, Fierce Healthcare [7/17/23]

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CMS: A New Primary Care Medicine Model

“MAKING CARE PRIMARY”

By Health Capital Consultants, LLC

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CMS Announces New Primary Care Model

On June 8, 2023, the Centers for Medicare and Medicaid Services (CMS) announced the establishment of Making Care Primary (MCP) Model, a voluntary primary care model that will be tested in Colorado, Massachusetts, Minnesota, New Mexico, North Carolina, New York, New Jersey, and Washington.

Set to launch on July 1, 2024, the 10 ½ year model will seek to improve the coordination and management of care, enable primary care clinicians to form relationships with healthcare specialists, and form community-based connections to address the health needs of patients, as well as health-related social needs such as nutrition and housing.
CITE: https://www.r2library.com/Resource

This Health Capital Topics article will discuss the new MCP Model and its implications for the healthcare industry. (Read more...)

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CMS: Projected National Health Expenditures to Surpass $7 Trillion Dollars

By Health Capital Consultants, LLC

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Projected National Health Expenditures to Surpass $7 Trillion

On June 14th, 2023, CMS released health insurance enrollment and national health expenditure (NHE) projections for 2022 through 2031.

CITE: https://www.r2library.com/Resource

The NHE, which is published annually, is the official U.S. estimate of insurance enrollment and health spending. CMS projects that from 2022 to 2031, the NHE’s annual growth rate of 5.4% will surpass the U.S. gross domestic product (GDP) annual growth rate of 4.6%. As a result, health spending as a share of the U.S. GDP is set to jump from 18.3% in 2021 to 19.6% in 2031.

This Health Capital Topics article will review the notable findings from CMS’s projection report. (Read more…) 

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CMS: “Open Payments” Pre-Publication Review & Dispute

NOW AVAILABLE

By Staff Reporters via CMS

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Open Payments is a national disclosure program that promotes a transparent and accountable healthcare system. Open Payments houses a publicly accessible database of payments that reporting entities, including drug and medical device companies, make to certain healthcare providers, which are referred to as covered recipients.

Pre-publication review and dispute for the Program Year 2022 Open Payments data opened on April 1st and is available through May 15th, 2023. Disputes must be initiated by May 15th, 2023 in order to be reflected in the June 2023 data publication. 

CITE: https://www.r2library.com

For more information on review and dispute timing and publication, refer to the Review and Dispute Timing and Data Publication Quick Reference Guide.

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PODCAST: CMS Over-Payments to Medicare Advantage [Part C] Plans

By Eric Bricker MD

RISK ADJUSTMENTS EXPLAINED

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Understanding the Mental Healthcare Regulatory Environment

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Appreciating the Rules

[By Carol Miller; RN, MBA]

Carol S. MillerLocal counties and municipalities are the primary providers of state mental healthcare for patients who lack private insurance coverage for such care.

Both children and adults may be eligible to receive assistance.

These counties provide a wide range of psychiatric and counseling services to the residents in their community as well as other types of assistance such as:

  • treatment services related to substance abuse;
  • housing;
  • employment services;
  • information and education service;
  • referrals;
  • consultative services to schools, courts and other agencies;
  • after-care services; and other related activities.

mental

Rules and Regulations

Accordingly, regulations from federal, state, and county governments have an impact on the day-to-day operations, procedures and processes of a county mental health center. Traditionally, there are three main types of regulations.

Federal Regulations — The United States healthcare system is guided by programs such as those established under the Centers for Medicare and Medicaid (in the case of county mental health programs, Medicaid is especially important), Americans with Disabilities Act (ADA), Occupational Safety and Health Administration (OSHA), Health Insurance Portability and Accountability Act (HIPAA), and others.

State Regulations — These include general legislative guidelines, state management of benefits and reimbursement of the Medicaid program, and state allocations of budgets, which impact the centers’ operations.

County Regulations — Each county defines its own County Mental Health Program and decides which services will be provided or excluded.

Assessment

County facilities generally include outpatient clinics, county mental health programs, short-term psychiatric facilities, day-care centers, de-toxification centers, residential rehabilitation centers for substance abuse, long-term care psychiatric facilities, and Veterans Affairs (VA) psychiatric centers. The county centers may be co-located with other county services such as social services, occupational rehabilitation services, information technology services, human resources, maintenance services, and others or may be independently located.

Conclusion

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PODCAST: Hospital “Out-Patient” Department Pricing Explained

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Hospitals Are Paid More for SAME SERVICE in Outpatient Department Than Doctors Are Paid in Office.

For Example, the SAME Echocardiogram Costs $600 in a Hospital Outpatient Department and $250 in a Doctor’s Office.

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PODCAST: Medicare Payment Bureaucracy Uncertainty

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Dr. Eric Bricker Explains How Medicare Can Take Money Back from Hospitals if it Wants. If the Hospital Thinks Medicare is Being Unfair, the Appeals Process Takes 3 Years!

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PODCAST: Medicare Re-Admission Penalty Explained

As part of the Affordable Care Act of 2010

CMS changed its hospital readmission penalty methodology

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PODCAST: Medicare Provider Payment Changes

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The Centers for Medicare and Medicaid Services (CMS) Announce Changes to Doctor and Healthcare Provider Payments

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CMS: MSSP ACO Growth 2012-2022

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DEFINITION: An accountable care organization is a healthcare organization that ties provider reimbursements to quality metrics and reductions in the cost of care. ACOs in the United States are formed from a group of coordinated health-care practitioners. They use alternative payment models, normally, capitation.

CITE: https://www.r2library.com/Resource/Title/0826102549

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CMS MSSP ACO Growth 2012-2022

Performance YearACOsAssigned Beneficiaries
202248311.0 million
202147710.7 million
202051711.2 million
201948710.4 million
201856110.5 million
20174809.0 million
20164337.7 million
20154047.3 million
20143384.9 million
2012+20132203.2 million

Source: CMS 2022 Shared Savings Program Fast Facts – As of January 1, 202

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Supreme Court Hears Oral Arguments on 340B Drug Pricing Cuts

BY HEALTH CAPITAL CONSULTANTS, LLC

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Supreme Court Hears Oral Arguments on 340B Cuts

On November 30, 2021, the U.S. Supreme Court heard oral arguments regarding the challenges arising from the cuts made by the Centers of Medicare & Medicaid Services (CMS) to the 340B Drug Pricing Program.

The 340B Drug Pricing Program allows hospitals and clinics that treat low-income, medically underserved patients to purchase certain “specified covered outpatient drugs” at discounted prices (applying a ceiling to what drug manufacturers may charge certain healthcare facilities) – 25% to 50% of what providers would typically pay – and then receive reimbursement pursuant to the rates set forth in the Outpatient Prospective Payment System (OPPS) at the same rate as all other providers. (Read more…)

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HEALTH ECONOMICS CITE: https://www.r2library.com/Resource/Title/0826102549

PODCAST: https://medicalexecutivepost.com/2021/08/27/podcast-hospital-340-b-drug-programs/

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TELE-MEDICINE Fraud, Abuse and New Barriers!

Telemedicine: Fraud and Abuse During the COVID Pandemic

By Susan Walberg

The COVID-19 pandemic has brought with it huge challenges for people all over the world; not only the obvious health-related concerns but also shutdowns, unemployment, financial difficulties, and a variety of lifestyle changes as a result.

When the COVID pandemic struck, CMS quickly recognized that access to care would be an issue, with healthcare resources strained and many providers or suppliers shutting down their offices or drastically limiting availability. Patients who needed routine care or follow-up visits were at risk for not receiving services during a time when healthcare providers were scrambling to enhance infection control measures and implement other new safety standards to protect patients and healthcare workers.

The Centers for Medicare and Medicaid Services (CMS) has responded by easing restrictions and regulatory burdens in order to allow patients to receive the healthcare services they need without undue access challenges. One key area that has changed is the restrictions related to telehealth services, which were previously only paid by Medicare under certain circumstances, such as patients living in remote areas.

Among the changes and waivers CMS has offered, telemedicine reimbursement is among the more significant. Telemedicine services, which includes office visits and ‘check ins’ are now allowed and reimbursed by Medicare. In addition to reimbursement changes, CMS has also relaxed the HIPAA privacy and information security enforcement standards, paving the way for providers to adopt a new model of providing services electronically.

TELE-HEALTH BARRIERS: https://www.statnews.com/2021/07/13/telehealth-provisions-emergency-patients/

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New Study Compares Medicare-Commercial Payment Gaps by Specialty

New Study Compares Medicare-Commercial Payment Gaps by Specialty

BY HEALTH CAPITAL CONSULTANTS


Utilizing data from FAIR Health, the Urban Institute conducted an October 2021 study which reviewed commercial insurance claims across the U.S. (for approximately 60 insurers and third-party administrators covering over 150 million Americans under age 65) from March 2019 through February 2020.

CITE: https://www.r2library.com/Resource/Title/0826102549

This study assessed the gap between commercial insurance payments and Medicare payments for professional physician services to determine whether the payment gap between Medicare and commercial insurance differs by specialty. (Read more…)

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CMS Innovation Center Launches “Bold New” Strategy

BY HEALTH CAPITAL CONSULTANTS, LLC

CMS Innovation Center Launches “Bold New” Strategy


When President Joe Biden was elected in 2020, there was much anticipation and speculation regarding what his election would mean for the U.S. healthcare industry in the coming years.

CITE: https://www.r2library.com/Resource/Title/0826102549

Thriving in a value-based health care model - Biotricity

As an ardent supporter of the Patient Protection and Affordable Care Act (ACA) who campaigned on offering a public insurance option similar to Medicare, many in the healthcare industry assumed that the Biden Administration would be a strong proponent of continuing the shift to value-based care, which shift was largely spurred by his predecessor and former boss, Barack Obama, with the passage of the ACA. (Read more…)

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PODCAST: Medicare Hospital Re-Admission Penalties

EXPLAINED!

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COVID-19 UPDATE: Vaccine Booster Shots

BY MEDICARE TEAM

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Important update on COVID-19 vaccine booster shots
If you previously got 2 doses of the Pfizer-BioNTech COVID-19 vaccine, you can get a booster shot of the Pfizer-BioNTech COVID-19 vaccine if you fall into one of these groups:

You’re 65 and older,You’re 18+ and have certain underlying medical conditions, or
You’re 18+ and work or live in a high-risk setting.

You can get your booster shot at least 6 months after you complete your second dose of the Pfizer vaccine.
The booster shot can help strengthen and prolong your protection against COVID-19.

Learn More: Visit CDC.gov for more information on other groups already vaccinated with the Pfizer vaccine that may be eligible for a booster shot.

Remember: Medicare covers a Pfizer vaccine booster shot at no cost to you.

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Oregon says it's ready to provide COVID-19 booster shots to those eligible,  but asks for patience - KTVZ

Sincerely,
The Medicare Team
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PODCAST: APPEALS of Medicare Advantage [Part C] Plans

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PODCAST: Medicare Financial Matters

WHAT COUNTS AS INCOME SOURCES?

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Risk Management, Liability Insurance, and Asset Protection Strategies for Doctors and Advisors : Best Practices from Leading Consultants and Certified Medical Planners™ book cover

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Comprehensive Financial Planning Strategies for Doctors and Advisors: Best Practices from Leading Consultants and Certified Medical Planners™

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PODCAST: Why Insurance Carriers Want MEDICARE-FOR-ALL

WHY M-4-A?

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CMS Releases 2022 Physician Fee Schedule Proposed Rule

CMS RELEASES CY 2022 Physician Fee Schedule Proposed Rule


On July 13, 2021, the Centers for Medicare & Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2022.

CITE: https://www.r2library.com/Resource/Title/0826102549

In addition to numerous payment updates in the MPFS, such as significant updates to the Merit-based Incentive Payment System (MIPS), new policies may preserve expanded telemedicine services through 2023 and clinicians may incur more difficulty earning bonuses under the Quality Payment Program (QPP) eligibility threshold. CMS also includes in the proposed rule a request for information to address COVID-19 vaccine reimbursement proposals. (Read more...)

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CMS Includes Changes in CY 2022 OPPS Proposed Rule

BY HEALTH CAPITAL CONSULTANTS, LLC

CMS Includes Several Changes in CY 2022 OPPS Proposed Rule


On July 19, 2021, CMS released the proposed rule for the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Centers (ASCs) for calendar year (CY) 2022. The proposed rule builds on President Joe Biden’s July 9, 2021 executive order on “Promoting Competition in the American Economy,” as it relates to increasing access and price transparency in the healthcare industry.

Outpatient Prospective Payment System (OPPS) Project. Understanding  Ambulatory Payment Classification (APC) - PDF Free Download

CITE: https://www.r2library.com/Resource/Title/0826102549

In a press release regarding the proposed rule, CMS stated their commitment to addressing the persistent health inequities in the U.S. and finding opportunities to improve data collection that will lead to policy changes to help meet the health needs of patients. (Read more…)

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CMS: Open Payment Data

OPEN PAYMENTS DATA SEARCH TOOL

By Dr. David Edward Marcinko MBA

The Open Payments Search Tool is used to search payments made by drug and medical device companies to physicians and teaching hospitals.

CMS releases star ratings; nearly 10% of hospitals earn ...

WEBSITE: https://openpaymentsdata.cms.gov/

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The Integrated Patient-Centered Medical Home Model

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Tools for Transforming Our Healthcare

By Matias A. Klein

[VP, General Manager, Clinical Quality and Collaboration, Portico Systems]

The patient-centered medical home (PCMH) continues to attract increasing attention from many industry stakeholders. The PCMH model has the potential to enhance the US healthcare system by rejuvenating primary care in a way that improves clinical outcomes, lowers costs, promotes wellness, and increases patient and physician satisfaction.

PCMH Pilot Programs

PCMH pilots are currently being tested in almost all states, including a 3-year Medicare medical home demonstration project overseen by the Centers for Medicare & Medicaid Services. However, few organizations have scaled the PCMH across their entire healthcare network, and the existing implementations appear to remain focused on care management at the expense of patient wellness. The value of focusing equally on promoting wellness (although an underappreciated nuance in the implementation of a PCMH) is a critical factor in effectively leveraging the PCMH model to improve clinical outcomes and the US healthcare system.

Centered on the Patient

The PCMH model, as its name suggests, is centered on the patient. The underlying thought is that if a comprehensive, longitudinal view of a patient is taken throughout a patient’s lifespan, the patient’s health could be better “managed” and better aligned with best medical practices. It is well documented that physicians do not consistently or frequently apply evidence based, recommended care to patients. Therefore, a major goal of the PCMH model is to improve the consistent application of evidence-based guidelines and best practices, by making longitudinal information about the patient available to providers and to patients – including any risks and recommended “intervention opportunities.” And although adherence to best practices in disease management is crucial, the PCMH model also focuses on preventing costly episodes by promoting and incentivizing wellness.

PCPs = Medical Homes

To effectively manage a patient’s health and promote wellness, primary care physicians – designated as medical homes – need to act as health “quarterbacks” or “coaches.” In such a role, these physicians will assist in aggregating a patient’s health information, making best practices transparent, offering health education and counseling, as well as coordinating the provisioning of any healthcare services the patient may need. With physicians spending significant time coaching and making critical clinical decisions, these services will be delivered with the support of care management nurses, who will handle the majority of the information processing and operational activity.

An Innovation in Care

The PCMH model is an important innovation in care delivery and has the potential to reduce medical and administrative costs, while improving the quality of care. However, how to implement the PCMH model within a care-delivery system remains unclear. Providers need the requisite infrastructure and capabilities at their locations to meaningfully participate in a PCMH. Patients must be engaged over long periods of time in proactively managing and improving their health. Outcomes and quality must be objectively measured to optimize the delivery of best possible patient care.

Potential Value

To realize the potential value of the PCMH, three distinct stakeholders – patients, providers, and health plans – must work in a collaborative way. Getting these stakeholders synchronized (i.e., aligned in their goals, using interoperable tools, and collaborating on an operational level) is no small feat but can be accomplished with the smart application of technology. Bringing these three stakeholder groups together on a common, collaborative technology platform results in what some are beginning to call the integrated PCMH. The integrated approach to the PCMH can best ensure that implementing a PCMH model does not create additional administrative burdens to health plans or provider organizations.

An integrated PCMH provides a framework for stakeholders to collaborate in a transparent fashion, and where quality, best practices, and outcomes are incentivized. The integrated PCMH also provides a pathway being awarded a medical home designation.

Vertical Integration Deployment

The key to deploying an integrated PCMH is an end-to-end vertical integration of the care-delivery process – that is, a process in which the provider network management, automation, information exchange, and analytics solutions are tightly integrated with patient and provider information. With so much complexity and so many “moving parts” in the delivery of the PCMH model, this end-to-end vertical integration is a practical solution that enables effective coordination of care and accurate measurement of quality: with such system integration, the provider network (e.g., the health plan) can bring economies of scale to even the smallest provider offices to optimize the quality of care delivery.

The 5 Keys

The five key components for such an integrated PCMH are:

  1. A source-of-truth for mapping medical home – designated providers, patients, as well as  the associated relationships with health plans and other medical professionals; a central medical home fact checking is critical for effectively identifying, managing, and communicating with medical home and their networks.
  2. A set of collaborative workflows that align stakeholders with best practices, incentives, and quality measures reporting; these collaborative workflows help each stakeholder understand where a given patient is in the care-delivery process, potential intervention opportunities, why certain interventions are being emphasized, and what incentives are available for executing specific interventions.
  3. An infrastructure for clinical integration and distribution of intervention opportunities, clinical reference content, education, alerts, and reminders. This infrastructure allows all stakeholders to have access to up-to-date, accurate patient information; it aligns stakeholders and helps reduce or eliminate duplication of procedures and tests.
  4. Interoperable clinical applications and collaboration tools to enable patients and physicians to engage in medical home processes; these tools – which include electronic medical records, e-prescribing, e-labs, secure e-mail, personal health records, and document management and exchange technology – can help manage health information, assist with decision-making, and improve communication between patients, providers, and health plans.
  5. Incentive management and analytics tools for modeling, setting, measuring, and rewarding incentives based on quality measures and outcomes; these tools must span the entire PCMH delivery process and are required for objectively evaluating and optimizing the performance of a medical home.

When considering the multiplicity of stakeholders, information, software systems, and knowledge that has to be coordinated in the context of a PCMH model, implementing a medical home pilot and scaling it to a full-blown network may seem a daunting task. The integrated PCMH offers a real-world solution for deploying a scalable and flexible infrastructure for the management of this emerging care-delivery model.

Assessment

Early evaluations of the PCMH model show promising, albeit inconclusive, outcomes. The integrated PCMH model offers a practical road map for deploying a management system that will enable objective measurement of PCMH performance and outcomes.

Conclusion

Although the jury is still out on the ultimate value of the PCMH, deploying an integrated PCMH system can help position PCMH pilots in a way that enhances their flexibility and scalability to support full-scale network transformation.

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

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