Monday, July 18, 2011

Hawaiians Die, Too -- But Less Often

Published 7/14/2011 
In 2009, the age-adjusted risk of dying was about 50% higher for a resident of West Virginia than it was for a resident of Hawaii.
The gap between the age-adjusted mortality rate for residents of Hawaii and residents of West Virginia, fell to 53% that year, from 57% in 2007, but, in 2009, West Virginia still recorded an age-adjusted death rate of 949.6 deaths per 100,000 residents, compared with an age-adjusted death rate of just 619.8 deaths per 100,000 residents for Hawaii.
Arialdi Minino, a researcher at the National Center for Health Statistics (NCHS), has reported the 2009 figures in a 2009 death report released by the center's parent agency, the U.S. Centers for Disease Control and Prevention. Minino and colleagues also prepared a similar report in 2007.
The jurisdictions with the highest age-adjusted 2009 death rates are mostly in or near the Southeast. They include Alabama, Arkansas, Georgia, Indiana, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee, West Virginia and the District of Columbia.
Mortality is high in the Southeast partly because many residents of the South are black, and there is still a gap between the life expectancy of white U.S. residents and black U.S. residents. The size of the life expectancy gap fell 22% between 2000 and 2009, but in 2009 white U.S. residents could still expect 4.3 years longer than black residents.
For white and black residents who are already 65 years old, the life expectancy gap was 1.3 years.
But NCHS researchers reported in a look at  age-adjusted death rates for the period from 2005 to 2007 that age-adjusted death rates for white residents of high-death-rate states also tend to be high.
In Hawaii, for example, the age-adjusted death rate per 100,000 white residents was just 665.9; the age-adjusted death rates for 100,000 white residents in the Southeast were 952.0 in West Virginia and 904.9 in Louisiana.
In some states, the age-adjusted death rate for black residents is much lower than the age-adjusted death rate for white residents. Those states are Alaska, Hawaii, Idaho, Maine, Montana, New Hampshire, New Mexico and Wyoming.

New Private Nonprofit Health Plans Will Increase Competition, Give Consumers and Small Businesses More Health Insurance Choices

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Room 352-G
200 Independence Avenue, SW
Washington, DC 20201
Office of Media Affairs


FOR IMMEDIATE RELEASE                                Contact: CMS Media Relations Group
July 18, 2011                                                                                                  (202) 690-6145



New Private Nonprofit Health Plans Will Increase Competition, Give Consumers and Small Businesses More Health Insurance Choices

Today, the Centers for Medicare & Medicare Services (CMS) took steps to encourage the creation of Consumer Operated and Oriented Plans (CO-OPs), new private non-profit, consumer-governed health insurance plans that will help increase competition and give consumers and small businesses additional affordable health insurance choices.  CMS is proposing standards for CO-OPs, and for qualifying for $3.8 billion in repayable loans to help start-up and capitalize these new health plans. All CO-OP loans must be repaid with interest and loans will only be made to private, nonprofit entities that demonstrate a high probability of becoming financially viable.

CO-OPs are designed to give consumers and small businesses control over their own health insurance.  CO-OPs are private, non-profit insurers governed by their members and offering affordable, consumer-friendly health insurance options.  CO-OPs will use any profits to benefit its members, including actions to lower premiums, improve health benefits, improve the quality of members’ health care, expand enrollment, or otherwise contribute to the stability of coverage for members.

“CO-OPs will provide consumers more choices, greater plan accountability, and help ensure a more competitive insurance market,” said Steve Larsen, Director of the Center for Consumer Information and Insurance Oversight.  “Today’s announcement shows how the Affordable Care Act is bringing new choices and giving consumers a voice in insurance markets throughout the nation.”

Working from the recommendations of the public advisory committee, the rules proposing the framework were developed with significant input from many stakeholders, including testimony at public meetings from consumers, small businesses and health care providers.   The proposed rule is only a first step.  CMS is taking public comment on the proposal and expects to release a Funding Opportunity Announcement regarding the availability of loans to start up CO-OPs soon.

The CO-OP program provides for loans to private entities with the goal to create a new CO-OP in every State to expand the number of Exchange health plans with a focus on consumer accountability. The CO-OP program contains extensive provisions to protect against fraud, waste, and abuse.  Loan recipients are subject to strict monitoring, audits, and reporting requirements for the length of the loan repayment period plus 10 years.  Recipients must submit semi-annual program reports and quarterly financial statements. Additionally, CMS will conduct audits, including site visits, as appropriate.  CO-OPs must meet a series of milestones as laid out in their loan term agreements before drawing down any money from the program.

CO-OPs will sell coverage through the State’s Affordable Insurance Exchange as well as have the opportunity to sell coverage to small businesses through the State’s Small Business Health Option Programs (SHOP Exchanges).Several successful health insurance cooperatives currently exist around the country, covering nearly 2 million individuals.  A number of diverse groups are organizing to take advantage of this new opportunity.  In one state, primary care providers are working to create a CO-OP to focus on care for rural areas.  In another, a CO-OP steering committee has been formed by interested physicians, technology and business experts, and community groups.

For more information on today’s announcement, read the fact sheet at www.HealthCare.gov/news/factsheets/coops07182011a.html.

Further information on the Consumer Operated and Oriented Plan program, including the determinations of the Federal Advisory Board and information for prospective applicants, can be found at: cciio.cms.gov/programs/coop/index.html

The full text of the Notice of Proposed Rulemaking can be found at http://www.ofr.gov/OFRUpload/OFRData/2011-18342_PI.pdf or http://www.ofr.gov/inspection.aspx
CMS will accept comments on the proposed rule until  September 16, 2011. 

Friday, July 15, 2011

House Plans Vote to Slash Medicare and Social Security through Balanced Budget Amendment

Next week, the House of Representatives is scheduled to vote on a proposal that will directly impact and harm Medicare beneficiaries, Social Security recipients, and others that rely on critical safety net programs. The Goodlatte-Walsh Balanced Budget Amendment, H.J.Res.1, will come to a vote Wednesday, July 20. The bill requires Congress to pass a balanced budget every fiscal year and cap federal spending to 18% of the Gross Domestic Product.[1] Spending caps, as we have written before, threaten the Medicare and Medicaid programs and hurt beneficiaries and their families.[2] The proposed Amendment would lead to a drastic 47% spending cut in programs like Social Security and Medicaid by the year 2035. These proposed cuts would leave spending at levels not seen since 1956, before the Medicare program existed, and far below the levels recommended by the Bowles-Simpson Commission.[3],[4]

In addition to imposing draconian cuts to programs and the people who depend on those essential programs, the proposed bill would require a 2/3 majority in Congress to raise revenues, and require a 3/5 majority to vote to raise the debt limit. These provisions place the burden of our economic deficit squarely on the shoulders of older people, people with disabilities, and middle class Americans while leaving the wealthiest Americans and corporations untouched. Further, economists argue a BBA would threaten economic recovery and, according to economist Norman Ornstein, "virtual[ly] guarantee that we will have economic catastrophes that will make the Great Depression look like a picnic."[5]

While we must get our financial house in order, attempting to do so through a Balanced Budget Amendment approach that slashes Social Security, Medicare, and other programs that Americans rely on is short-sighted and would have devastating effects on our economy and jobs at a time when many are struggling. 


[1] Office of Congressman Joe Walsh, "Goodlatte-Walsh Balanced Budget Amendment Scheduled for Vote on House Floor", available at:http://walsh.house.gov/index.cfm?sectionid=49§iontree=6,49&itemid=250.[2] Center for Medicare Advocacy, "Why Medicaid Matters to People with Medicare," available at:http://www.medicareadvocacy.org/2011/06/
why-medicaid-matters-to-people-with-medicare/
.[3] Center for Budget Policy and Priorities, "Statement by Robert Greenstein on Proposed Balanced Budget Amendment," available at:http://www.cbpp.org/cms/index.cfm?fa=view&id=3442.[4]Norman Ornstein, American Enterprise Institute for Public Policy Research, Articles and Commentary, available at:http://www.aei.org/article/103390.[5] Ibid.

New Initiatives to Improve Services for Dual Eligibles

The Centers for Medicare & Medicaid Services (CMS) recently announced several new initiatives focused on improving care for people who are eligible for both Medicare and Medicaid (dual eligibles).

Two initiatives relate to providing fully integrated services to dual eligibles, through both capitation and fee-for-service structures.  A third initiative addresses preventing unnecessary hospitalizations of nursing home residents, with special focus on nursing facilities that serve high numbers of dual eligibles and that have high hospitalization rates.  Finally, CMS announced the creation of a resource center to "assist States in delivering coordinated health care to high-need, high-cost beneficiaries."[1]  The goals of the resource center are to help States "to better serve beneficiaries, improve quality and reduce costs."[2] This Alert offers some more information on the three initiatives.

Initiatives 1 and 2 - Integrated Services
In a State Medicaid Director letter (SMDL) dated July 8, 2011, the Centers for Medicare & Medicaid Services outlined two new models for States to use to integrate primary, acute, behavioral health, and long-term supports and services for their enrollees who are dual eligibles.[3]

The new initiative comes from the work of the Medicare-Medicaid Coordinating Office (MMCO), which was established under authority of the Affordable Care Act to improve access to health care services for dual eligibles and to address issues of the high cost of care for that population.  In an earlier initiative, MMCO awarded contracts to 15 States to develop plans to integrate services.[4]

The capitated model contemplates a three-way contract between a State, CMS, and a health plan.  The plan will receive a capitated rate that is a blend of the Medicare and Medicaid rates to provide all benefits of both programs.  The blended rate is expected to provide savings for both States and the federal government.  The model anticipates testing certain flexibilities, including the provision of supplemental benefits, enrollment flexibilities, uniform appeals, audit, and marketing rules and procedures.  Under current law, each program may have different rules in such areas, making it complicated for a single plan to meet both sets of standards.

The fee-for-service model seeks to address an issue that has long been raised by States.  That is, if States improve quality and provide better long-term supports and services, beneficiaries may have fewer Medicare-paid-for hospitalizations, but the States do not get the benefit of the Medicare savings.  The new model allows States to share in Medicare savings that are produced by serving dual eligibles more efficiently and effectively.

The SMDL includes templates of Memoranda of Understanding relating to both models.

Initiative 3 - Improved Care Quality for Nursing Facility Residents
This demonstration is offered through collaboration between the MMCO and the Center for Medicare and Medicaid Innovation (CMMI), which was authorized by the Affordable Care Act to test a variety of payment models to improve health care without increasing cost or to reduce cost without reducing quality.  According to the CMS press release, the initiative addresses "a wide-spread and costly problem:  nursing facility residents are subject to frequent preventable inpatient hospitalizations" that are potentially harmful to the residents and very costly to Medicare.[5]

Under the nursing home demonstration, CMS will contract with independent entities (i.e., outside the nursing facility's staff) to provide enhanced clinical services to people in 150 skilled nursing facilities nationwide.  Such services could include focus on improving transitions between hospitals and skilled nursing facilities and implementing better practices to prevent the conditions that often lead to hospitalizations:  falls, pressure ulcers, and urinary tract infections.
As noted above, CMS will target facilities with high rates of hospitalization and high numbers of dual eligibles among their residents.

One concern about this initiative arises in connection with how "hospitalization" is defined when measuring the success of interventions.  Quality measures generally look at "inpatient" hospitalizations when calculating the rate of "hospitalizations" and "rehospitalizations."  In recent years, the Center for Medicare Advocacy has seen a substantial increase in the numbers of Medicare beneficiaries whose hospital stay is labeled as "observation" status rather than "inpatient" status.[6]  In the context of this initiative, a hospital stay on "observation status" could lead to an incorrect conclusion that the particular intervention has been successful, when, in fact, the resident was subject to all the potential bad outcomes associated with inappropriate hospitalizations.

Conclusion
The new initiatives offer promise of improved care for the sickest and frailest individuals in our society.  They also come with a clear emphasis on reducing the costs to Medicare and Medicaid of caring for these most vulnerable individuals.  Advocates will have to stay engaged with the process as details of the initiatives unfold to ensure that strong beneficiary protections are woven into all aspects of the initiatives.[7]  The Center will continue to analyze and write about these initiatives as details are reported.

For more information, contact attorney Patricia Nemore (pnemore@medicareadvocacy.org) in the Center for Medicare Advocacy's Washington, DC office at (202) 293-5760.
 

[1]  CMS, "Obama Administration Offers States New Ways to Improve Care, Lower Costs for Medicaid; Initiatives Focus on People Receiving Medicare and Medicaid Benefits." Press Release (July 8, 2011) at:http://www.cms.gov/apps/media/press/release.asp?Counter=4024&intNumPerPage=
10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=
0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=
&showAll=&pYear=&year=&desc=&cboOrder=date
See also CMS, "Testing Financial Models to Support State Efforts to Coordinate Care for Medicare-Medicaid Enrollees; Two New Models Available to States to Improve Quality and Decrease Costs," Fact Sheet (July 8, 2011) at:
https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4023&intNumPerPage=
10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=
All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
.
[2] Id.[3] Letter from Cindy Mann, Director, Center for Medicaid, CHIP and Survey & Certification, and Melanie Bella, Director, Medicare-Medicaid Coordination Office, to State Medicaid Directors, re:  Financial Models to Support State Efforts to Integrate Care for Medicare-Medicaid Enrollees, SMDL #11-008, ACA #18 (July 8, 2011) at:https://www.cms.gov/smdl/downloads/Financial_Models_
Supporting_Integrated_Care_SMD.pdf
.[4] The 15 states are:  CA, CO, CT, MA, MI, MN, NY, NC, OK, OR, SC, TN, VT, WA, WI[5] CMS, "Demonstration to Improve Care Quality for Nursing Facility Residents; Initiative to Reduce Preventable Hospitalizations," Fact Sheet (July 8, 2011) at:
https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4022&intNumPerPage=
10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=
All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date
.
[6] See Extended Observation Stays in Acute Care Hospitals:  Criticism, Legislation and Discussion at:
http://www.medicareadvocacy.org/InfoByTopic/ObservationStatus/
10_08.26.ObservationStatusCriticismEtc.htm
and Preventable Emergency Department Visits by Nursing Home Residents at:http://www.medicareadvocacy.org/InfoByTopic/SkilledNursingFacility
/10_08.19.PreventableEmergencyVisits.htm

[7]   See, e.g. Letter of December 13, 2010 from 38 organizations and individuals to Secretary Sebelius and  attached Recommendations for Beneficiary Protections in Models Approved by the Center for Medicare and Medicaid Innovations, available at:
http://www.medicareadvocacy.org/2011/07/
recommendations-for-beneficiary-protections-in-models-approved-by-cmmi/
.   See also, Kevin Prindiville and Georgia Burke, Ensuring Consumer Protections for Dual Eligibles in Integrated Models,  July 2011 at:
http://www.nsclc.org/areas/medicare-part-d/
Issue-Brief-Ensuring-Consumer-Protection-for-Duals.

CMS Releases Proposed Rules for Medicare Payments

The current threat to Medicare and Medicaid is very real. The debt-ceiling debate has somehow turned into a referendum on the future of these essential health programs, and in turn on the financial outlook, health, and quality of life of older Americans, people with disabilities, and their families. In a statement I issued this week about the current state of negotiations, I called for a balanced approach that would not result in major cost-shifting to Medicare beneficiaries who are not able to bear the burden of extra costs. 

Read Joe Baker’s statement.

We can all play a part in preventing deep cuts to Medicare and Medicaid. Take action, and encourage family and friends to do the same, by contacting your elected officials to let them know that these programs are essential. Share with your senators and representatives your stories about how you and your family have come to rely on these programs, and let them know that proposed changes to these programs will impact all Americans. Send the message that any final resolution to deficit-reduction conversations must take a balanced approach that includes increased revenue. Make it clear that proposals that cut federal government spending on Medicaid and Medicare by shifting cost responsibility to states and Medicare beneficiaries will result in Medicaid benefit reductions, decreased access to health care, and increased out-of-pocket costs for older Americans and people with disabilities.

To contact your elected official, call the Congressional switchboard at 202-224-3121 and ask to be connected to your senators’ or representative’s office. 

CMS Releases Proposed Rules for Medicare Payments

The current threat to Medicare and Medicaid is very real. The debt-ceiling debate has somehow turned into a referendum on the future of these essential health programs, and in turn on the financial outlook, health, and quality of life of older Americans, people with disabilities, and their families. In a statement I issued this week about the current state of negotiations, I called for a balanced approach that would not result in major cost-shifting to Medicare beneficiaries who are not able to bear the burden of extra costs. 

Read Joe Baker’s statement.

We can all play a part in preventing deep cuts to Medicare and Medicaid. Take action, and encourage family and friends to do the same, by contacting your elected officials to let them know that these programs are essential. Share with your senators and representatives your stories about how you and your family have come to rely on these programs, and let them know that proposed changes to these programs will impact all Americans. Send the message that any final resolution to deficit-reduction conversations must take a balanced approach that includes increased revenue. Make it clear that proposals that cut federal government spending on Medicaid and Medicare by shifting cost responsibility to states and Medicare beneficiaries will result in Medicaid benefit reductions, decreased access to health care, and increased out-of-pocket costs for older Americans and people with disabilities.

To contact your elected official, call the Congressional switchboard at 202-224-3121 and ask to be connected to your senators’ or representative’s office. 

Thursday, July 14, 2011


Published 7/13/2011 
WASHINGTON BUREAU -- State insurance commissioners who want to help health insurance agents and brokers cope with the new medical loss ratio (MLR) rules apparently have decided that a behind-the-scenes strategy has the best change of succeeding.
A week ago, the National Association of Insurance Commissioners (NAIC), Kansas City, Mo., looked as if it were about to support H.R. 1206, a bill introduced by Rep. Mike Rogers, R-Mich., that would exclude producer compensation from MLR calculations.
The NAIC’s Professional Health Insurance Advisors Task Force endorsed the bill June 30.
Yesterday, the effort to get the NAIC as a whole to back to the bill died during a conference call meeting that included the NAIC's executive committee and the NAIC's plenary -- the assembly that includes all voting NAIC members.
The NAIC “chose not to take further action on the task force’s recommendation, but to continue to work with [the U.S. Department of Health and Human Services (HHS)] on other possible alternatives,” the NAIC executive committee said in a statement.
Kevin McCarty, the Florida insurance commissioner and incoming NAIC president, issued a statement after the call indicating that he is not dropping his support for an exemption but is changing his approach.
“Commissioner McCarty has not changed his position, and continues to support the bill sponsored by Mike Rogers, R-Mich., which would remove sales agents’ fees from the administrative costs of insurers for calculation of the medical loss ratio,” officials representing McCarty said in the statement.
The Professional Health Insurance Advisors Task Force is continuing to work with all interested parties and HHS to “evaluate the possibility of a compromise that would result in a more timely result than pursuing a change in the MLR,” officials said.
McCarty “continues to support the underlying purpose of the Rogers bill, which is to maintain the role of agents, and fair compensation for health insurance agents,” officials said.
Producers have turned to members of Congress and state insurance regulators for help because of concerns about the MLR provisions in the Patient Protection and Affordable Care Act of 2010 (PPACA), which require insurers to spend 85% of large group revenue and 80% of individual and small group revenue on health care and quality improvement efforts.
HHS has issued interim regulations that classify producer compensation as an administrative expense for purposes of MLR calculations.
Agents and brokers say insurers are using the PPACA MLR provision to justify cutting individual and small group producer commission rates as much as 50%.
Producers have argued that the customers are the ones who really pay the commissions, and that the insurers simply collect the commissions as a courtesy to the customers. The producers have asked regulators to reflect that view by keep producer commission payments out of the MLR formula.
Some consumer representatives -- individuals that the NAIC has picked to represent consumers in NAIC proceedings -- say there is evidence that health insurance commission levels and consumer access to health insurance agents and brokers may be more stable than producers have suggested.
Janet Trautwein, chief executive officer of the National Association of Health Underwriters NAHU has provided the NAIC and HHS with a 120-page report showing the devastating impact the MLR provision is having on health insurance producers, especially those serving the individual and very-small group market, Trautwein said.

The companies serving these markets have been cutting services, closing up, or laying off employees as a result of the federal MLR provision, Trautwein said.

Negotiations with HHS are ongoing, and “HHS has modified or delayed many other provisions of the health care law that have been criticized by interested parties,” Trautwein said.

Ethan Rome, executive director of Health Care for America Now, Washington, a group that supports PPACA, said the NAIC executive committee decision not to back H.R. 1206 is a “victory for consumers and businesses.”

“I think it does send a clear message to Congress that this is not an issue that should be taken up, because it is simply too divisive,” Rome said.

H.R. 1206 asks members of Congress to pick winners and losers, and it pits brokers against consumers and all small businesses, Rome said.

Implementing the bill as law would “take $1.3 billion in rebates from consumers and give it to the insurance companies without any guarantees that it will solve any of the problems that brokers have raised,” Rome said.

Trautwein said any rebates consumers get as a result of the MLR provision “will likely be quite modest.”

Social Security Announces New Compassionate Allowances Conditions

These are great reports..

CSG Actuarial today published its Free July CSG Report, featuring competitive intelligence data for the Long Term Care and Medicare Supplement markets. This month’s publication includes:

· Medicare Supplement Rate Increase Filings
· Long Term Care Underwriting Data on Circulatory Status
· Long Term Care - By the Numbers

Click HERE to download a free copy (or click on the image).

CSG continues to monitor various senior markets and strives to provide the most up-to-date competitive intelligence in the industry. Our database currently includes competitive information on more than 90 companies. For more information, please call (402) 502-7747, email info@csgactuarial.com This e-mail address is being protected from spambots. You need JavaScript enabled to view it , or visit csgactuarial.com.

Wednesday, July 13, 2011

Medicare Fraud Detection Program Hasn't Helped

Published 7/12/2011

A Medicare cost saving program that is supposed to save about $187 million between 2006 and 2018 may not have saved anything.
Joel Willemssen, managing director of the U.S. Government Accountability Office (GAO), gave that assessment today in testimony presented at a hearing organized by the Senate Homeland Security and Government Affairs Committee’s federal financial management subcommittee.
The subcommittee held the hearing to look at efforts to protect the integrity of the Medicare and Medicaid programs.
The federal Centers for Medicare and Medicaid Services (CMS), the arm of the U.S. Department of Health and Human Services that runs Medicare, started an Integrated Data Repository (IDR) program and a One PI program in 2006.
The IDR program was supposed to create a single source of Medicare and Medicaid claim data, and the One PI program was supposed to create a centralized portal for analyzing the data and looking for signs of fraudulent billing. CMS officials wanted analysts to be able to look to see, for example, when Medicare enrollees had apparently used ambulance services without using any other type of medical care.
CMS hired contractors to develop the tools and was supposed to have tools in place by 2009.
Parts of the IDR system have been in place since 2006, but the repository is still incomplete, Willemssen said, according to a written version of his remarks provided by the GAO.
“Program officials have not defined plans and reliable schedules for incorporating the additional data into IDR that are needed to support the agency’s program integrity goals,” Willemssen said.
Because of the project management problems, CMS officials stopped efforts to add more data to the repository after spending more than $80 million and more than 3 years on the effort, Willemssen said.

CMS deployed the One PI analysis system in 2009, but it is not widely used, in part because of problems with analyst training, Willemssen said.

There were supposed to be 639 analysts trained to use the system by October 2010, but only 42 were actually trained, Willemssaid said.

“Because IDR and One PI are not being used as planned, CMS officials are not yet in a position to determine the extent to which the systems are providing financial benefits or supporting the agency’s initiatives to meet program integrity goals and objectives,” Willemssen said.

CMS officials have suggested that the IDR project should cost about $90 million through 2018, provide a total of $187 million in financial benefits, and lead to $97 million in net benefits.

 “As of March 2011, program officials had not identified actual financial benefits of implementing IDR,” Willemssen said.
Similarly, because of the relatively low level of use of the One PI system, there are “not enough data available to quantify financial benefits attributable to the use of the system,” Willemssen said.

“Until CMS is better positioned to identify and measure financial benefits and establishes outcome-based performance measures to help gauge progress toward meeting program integrity goals, it cannot be assured that the systems will contribute to improvements in CMS’s ability to detect fraud, waste, and abuse in the Medicare and Medicaid programs, and prevent or recover billions of dollars lost to improper payments of claims,” Willemssen said.

Quote of the Day

Tuesday, July 12, 2011

AAA Rep Urges Congress to Increase Retirement Age

Published 7/8/2011 

To keep Social Security solvent, Congress should start by increasing the normal Social Security retirement age, a top actuary testified today on Capitol Hill.

Thomas Terry, chairperson of the public interest committee at the American Academy of Actuaries (AAA), Washington, appeared at a hearing on Social Security program finances organized by the House Ways and Means Committee’s Social Security subcommittee.
Actuaries started the AAA to give policymakers help with actuarial analysis.
Traditionally, the AAA has not taken positions on major policy debates, but, because of concerns about the long-range solvency of Social Security, the group decided in 2008 to advocate for a position for the first time, Terry said, according to a written version of testimony.
The position is a call for increasing the Social Security retirement age.
“Actuaries believed it was necessary to strongly recommend for the expeditious consideration of an adjustment to the Social Security program to help put it on a path toward sustainable solvency,” Terry said.
Social Security program trustees have been warning that the program is out of actuarial balance for more than two decades, and that means, that, as soon as 2036, the program may be unable to pay benefits in full in a timely fashion, Terry said.

“Adjusting the system today means that changes can be phased in slowly over many years,” Terry said. “Ignoring the projections and deferring needed adjustments to the future will result only in more difficulty down the road.”

The change is necessary because Americans are living longer and spending more years living in retirement, Terry said.
Congress could use many approaches to increasing the normal retirement age, Terry said.

Strategies could include simply raising the normal retirement age, indexing the retirement age so that life expectancy at the normal retirement age remains constant, or adjusting the normal retirement age to maintain Social Security program actuarial balance, Terry said.

To help older workers who face age discrimination, Congress could take steps such as promoting employment of older workers by reducing the payroll tax for older workers, Terry said.

“Difficulty in continuing to work in occupations that involve physical labor could be addressed by additional occupational bridge pensions, perhaps combined with revisions to existing disability programs,” Terry said.
Terry suggested modest changes in inflation adjustments also could help bring the Social Security program back into actuarial balance.

Monday, July 11, 2011

HHS News

HHS Office of the Inspector General reports that 61% of Medicare-provided power wheelchairs were medically unneeded or undocumented, costing $95 million in 6 months.

Partnership for Patients Meets Goal of Over 2,000 Hospitals Participating

HHS and states move to establish Affordable Insurance Exchanges

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Room 352-G
200 Independence Avenue, SW
Washington, DC 20201
Office of Media Affairs

FOR IMMEDIATE RELEASE                                                                                         Contact:  HHS Press Office
Monday, July 11, 2011                                                                                                                     (202) 690-6343
                                                             
HHS and states move to establish Affordable Insurance Exchanges, give Americans the same insurance choices as members of Congress

Proposed rules offer states flexibility, choices, competition and clout for
consumers and small businesses

Today, the U.S. Department of Health and Human Services (HHS) proposed a framework to assist states in building Affordable Insurance Exchanges, state-based competitive marketplaces where individuals and small businesses will be able to purchase affordable private health insurance and have the same insurance choices as members of Congress.  Starting in 2014, Exchanges will make it easy for individuals and small businesses to compare health plans, get answers to questions, find out if they are eligible for tax credits for private insurance or health programs like the Children’s Health Insurance Program (CHIP), and enroll in a health plan that meets their needs. 

“Exchanges offer Americans competition, choice, and clout,” said HHS Secretary Kathleen Sebelius. “Insurance companies will compete for business on a transparent, level playing field, driving down costs; and Exchanges will give individuals and small businesses the same purchasing power as big businesses and a choice of plans to fit their needs.”

Today’s announcement is designed to help support and guide states in their efforts to implement Exchanges.  HHS proposed new rules offering states guidance and options on how to structure their Exchanges in two key areas:
·       Setting standards for establishing Exchanges, setting up a Small Business Health Options Program (SHOP), performing the basic functions of an Exchange, and certifying health plans for participation in the Exchange, and;
·       Ensuring premium stability for plans and enrollees in the Exchange, especially in the early years as new people come in to Exchanges to shop for health insurance.
These proposed rules set minimum standards for Exchanges, give states the flexibility they need to design Exchanges that best fit their unique insurance markets, and are consistent with steps states have already taken to move forward with Exchanges. 

Forty-nine states, the District of Columbia and four territories accepted grants to help plan and operate Exchanges.  In addition, over half of all states are taking additional action beyond receiving a planning grant such as passing legislation or taking Administrative action to begin building exchanges.  States will continue to implement exchanges on different schedules through 2014.

“States are leading the way in implementing health reform, and today’s announcement builds on that momentum by giving states flexibility to design the Exchange that works for them,” said Center for Consumer Information and Insurance Oversight Director Steve Larsen.  “This regulation allows us to meet states where they are.”
Today’s proposals build on over a year’s worth of work with states, small businesses, consumers and health insurance plans and offer states substantial flexibility. For example, it allows states to decide whether their Exchanges should be local, regional, or operated by a non-profit organization, how to select plans to participate, and whether to partner with HHS to split up the work.

In drafting these proposals, the administration examined models of Exchanges, held numerous meetings with stakeholders and consulted closely with state leaders, consumer advocates, employers and insurers. To continue that conversation, HHS is accepting public comment on the proposed rules over the next 75 days to learn from states, consumers, and other stakeholders how the rules can be improved and HHS will modify these proposals based on feedback from the American people. To facilitate that public comment process, HHS will convene a series of regional listening sessions and meetings. 

To reduce duplication of effort and the administrative burden on the states, HHS also announced that the federal government will partner with states to make Exchange development and operations more efficient.  States can choose to develop an Exchange in partnership with the federal government or develop these systems themselves.  This provides states more flexibility to focus their resources on designing the right Exchanges for their local insurance markets.

For more information on Exchanges, including fact sheets, visit http://www.healthcare.gov/exchanges.

Thursday, July 7, 2011

Medicare expands coverage for patients with pacemakers that are FDA-approved for use with MRI exams

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Room 352-G
200 Independence Avenue, SW
Washington, DC 20201
Office of Media Affairs

MEDICARE NEWS


FOR IMMEDIATE RELEASE                                                             Contact: CMS Media Relations Group
July 7, 2011                                                                                                                                                          (202) 690-6145


Medicare expands coverage for patients with pacemakers that are FDA-approved for use with MRI exams

The Centers for Medicare & Medicaid Services (CMS) today expanded Medicare coverage of Magnetic Resonance Imaging (MRI) for beneficiaries with implanted pacemakers when used according to FDA-approved labeling in an MRI environment.  A final National Coverage Determination (NCD) posted today provides access to the MRI environment for patients with FDA-approved pacemakers.
On February 8, the Food and Drug Administration (FDA) approved the RevoMRI SureScan Pacing System, which is designed for use in the MRI environment for certain MRI exams.  Currently, there are no other pacemakers or implantable cardioverter defibrillators that are FDA-approved for use in the MRI environment.
“This swift action by CMS provides patients who need a pacemaker with greater access to MRI exams,” said Donald M. Berwick, M.D., CMS administrator.  “The expedited review of this decision demonstrates our commitment and support of new technology that will help improve the health of our beneficiaries.”
MRI is a noninvasive method of imaging that has the capability of demonstrating a wide variety of soft-tissue lesions in various parts of the body.  It is used to diagnose many medical conditions, such as cancer, and is used to look at various parts of the body, including the head, central nervous system, and the spine.  MRI also has advantages over other imaging techniques such as computed tomography (CT) and conventional radiographs, including no radiation exposure and easier visibility of soft tissue.
However, MRI exposes the patient to high magnetic and radio-frequency fields that may cause the movement or heating of implanted medical devices that are ferromagnetic (e.g. surgical clips) or that have ferromagnetic components (e.g. pacemakers, prostheses). The American College of Radiology’s (ACR) guidance document on safe MRI Practices (Kanal, 2007) explicitly discusses the need to address potential risks of exposure for patients that may have ferromagnetic foreign bodies or implants.
The final coverage policy issued today follows a proposed decision issued in April 2011.  The final decision memorandum is available on the CMS website at https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?&NcaName=Magnetic%20Resonance%20Imaging%20(MRI)%20(3rd%20Recon)&bc=ACAAAAAAIAAA&NCAId=252&.