Thursday, April 30, 2015

(CMS updates to the wage index and payment rates for the Medicare Hospice Benefit)




April 30, 2015


Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries


2016 Hospice NPRM CMS-1629-P

(CMS updates to the wage index and payment rates for the Medicare Hospice Benefit)



On April 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule (CMS-1629-P) that would update fiscal year (FY) 2016 Medicare payment rates and the wage index for hospices serving Medicare beneficiaries. The proposed hospice payment rule reflects the ongoing efforts of CMS to support beneficiary access to hospice care. The FY 2016 proposals and other issues discussed in the proposed rule are summarized below.


Changes to Payments under the Medicare Hospice Benefit

As proposed, hospices would see an estimated 1.3 percent ($200 million) increase in their payments for FY 2016. The $200 million increase in estimated payments for FY 2016 reflects the distributional effects of the 1.8 percent proposed FY 2016 hospice payment update percentage ($290 million increase), the use of updated wage index data and the phase-out of the wage index budget neutrality adjustment factor (-0.7 percent/$120 million decrease) and the proposed implementation of the new Office of Management and Budget (OMB) Core Based Statistical Areas (CBSA) delineations for the FY 2016 hospice wage index with a one-year transition (0.2 percent/$30 million increase). The elimination of the wage index budget neutrality adjustment factor (BNAF) was part of a 7-year phase-out that was finalized in the “Medicare Program; Hospice Wage Index for Fiscal Year 2010” final rule (74 FR 39384, Aug. 6, 2009), and is not a policy change.


Proposed Rule Details


Budget Neutrality Adjustment Factor phase-out

This proposed rule describes the final year of a provision of the FY 2010 Hospice Wage Index rule that phased out the BNAF. The BNAF was implemented in 1997, when the former Health Care Financing Administration (HCFA), now CMS, moved from an outdated wage index to a more current and accurate method for determining hospice payments. The FY 2010 Hospice Wage Index final rule finalized a schedule to phase-out the BNAF over seven years, reducing it by 10 percent in FY 2010 and by 15 percent reductions each year from FY 2011 through FY 2016.



Alignment of Cap Year

This proposed rule would seek to align the cap accounting year for both the inpatient cap and the hospice aggregate cap with the fiscal year for FY 2017 and later. This allows for the timely implementation of the IMPACT Act of 2014 changes (implementation in FY 2016) while better aligning the cap accounting year with the timeframes described in the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act of 2014). The IMPACT Act of 2014 mandates that the hospice aggregate cap be updated by the hospice payment update rather than using the CPI-U for a specified time. In addition, we will align the timeframe for counting the number of beneficiaries with the fiscal year, rather than the accounting year.


CBSA-OMB Delineations

This rule proposes to adopt changes to the delineation of Metropolitan Statistical Areas, Micropolitan Statistical Areas, and Combined Statistical Areas, and guidance on uses of the delineation of these areas reflected in the OMB Bulletin No. 13-01. These changes would be implemented using a blended wage index with a one-year transition, which aligns with the policy finalized for the Skilled Nursing Facility PPS and Home Health PPS in FY 2015 and calendar year (CY) 2015, respectively. For each county, a blended wage index would be calculated as fifty percent of the FY 2015 wage index using the current OMB delineations and fifty percent of the FY 2015 wage index using the revised OMB delineations.


Proposed Routine Home Care Rates

This rule proposes two different payment rates for routine home care (RHC) that would result in a higher base payment rate for the first 60 days of hospice care and a reduced base payment rate for 61 or more days of hospice care. These differing payment rates would further the goal of more accurately aligning the per diem payments with visit intensity and the cost of providing care.


Service Intensity Add-On

This proposed rule proposes a Service Intensity Add-On (SIA) Payment for FY2016 and beyond in conjunction with the proposed RHC rates. The proposed SIA payment is a payment that would be made for the last seven days of life in addition to the per diem rate for the Routine Home Care (RHC) level of care if certain criteria were met. The payment would not be made to providers with patients residing in SNF/NFs due to the concerns with the provision of hospice care in these settings as highlighted by the Office of Inspector General and the Medicare Payment Advisory Commission. The SIA payment policy encourages visits to patients at the end of life and improves provider accountability. Additionally, the policy begins to address industry and other organizations’ concerns regarding the need for increased payment for more resource intensive days.


Clarification Regarding Diagnoses on Claim Form

Based on the numerous comments received in previous rulemaking, and anecdotal reports from hospices, hospice beneficiaries, and non-hospice providers, we are concerned that some hospices are neither conducting a comprehensive assessment nor updating the plan of care as articulated by the Conditions of Participation to recognize the conditions that affect an individual’s terminal prognosis.


Therefore, we are clarifying that hospices are required to report all diagnoses identified in the initial and comprehensive assessments on hospice claims, whether related or unrelated to the terminal prognosis of the individual. This is in keeping with the requirements of determining whether an individual is terminally ill. This would also include the reporting of any mental health disorders and conditions that would affect the plan of care as hospices are to assess and


provide care for identified psychosocial and emotional needs, as well as, for the physical and spiritual needs.


The proposed rule went on display on April 30, 2015 at the Federal Register’s Public Inspection Desk and will be available under “Special Filings,” at or  

After 05/05/2015 this rule will be available online at



For further information, see Public comments on the proposal will be accepted until June 29, 2015.



New Medicare prescription drug cost data available



April 30, 2015


Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries


New Medicare prescription drug cost data available

Data serves as a rich resource for clearer look into Part D costs and services


As part of the Administration’s goals of better, care, smarter spending, and healthier people, the Centers for Medicare & Medicaid Services announced the availability of new, privacy-protected data on Medicare Part D prescription drugs prescribed by physicians and other health care professionals in 2013. This data shows which prescription drugs were prescribed to Medicare Part D beneficiaries by which practitioners.  


“This transparency will give patients, researchers, and providers access to information that will help shape the future of our nation’s health for the better,” said acting CMS Administrator Andy Slavitt. “Beneficiaries’ personal information is not available; however, it’s important for consumers, their providers, researchers, and other stakeholders to know how many prescription drugs are prescribed and how much they cost the health care system, so that they can better understand how the Medicare Part D program delivers care.”


The new data set contains information from over one million distinct health care providers who collectively prescribed approximately $103 billion in prescription drugs and supplies paid under the Part D program. The data characterizes the individual prescribing patterns of health providers that participate in Medicare Part D for over 3,000 distinct drug products. For each prescriber and drug, the dataset includes the total number of prescriptions that were dispensed, which include original prescriptions and any refills, and the total drug cost paid by beneficiaries, Part D plans, and other sources.


CMS created the new data set using drug claim information submitted by Medicare Advantage Prescription Drug plans and stand-alone Prescription Drug Plans. With this data, it will be possible to conduct a wide array of prescription drug analyses that compare drug use and costs for specific providers, brand versus generic drug prescribing rates, and to make geographic comparisons at the state level.


The Administration has set measurable goals and a timeline to move Medicare toward paying providers based on the quality, rather than the quantity, of care they give patients. This is part of a wide set of initiatives to achieve better care, smarter spending and healthier people through our health care system. Open sharing of data securely, timely and more broadly supports insight and innovation in health care delivery.


Today’s Part D prescriber data availability adds to the unprecedented information previously released on services and procedures provided to Medicare beneficiaries, including hospital charge data on common impatient and outpatient services as well as utilization and payment information for physicians and other healthcare professionals. In addition, under the Qualified Entity (QE) program, CMS releases Medicare data to approved entities for the purposes of producing public performance reports on physicians, hospitals, and other providers. To date, CMS has certified 11 regional QEs and one national QE.


To view a fact sheet on the Medicare Part D prescriber data, visit:

According to survey data from Gallup:

  • The percentage of uninsured Americans peaked at 18.0% in the third quarter of 2013
  • After the first enrollment period under the Affordable Care Act. the uninsured rate fell 1.5 points, from 17.1% for the fourth quarter of 2013 to 15.6% for the first quarter of 2014
  • After the second enrollment period under the Affordable Care Act, the uninsured rate fell one point, from 12.9% in the fourth quarter of 2014 to to 11.9% in the first quarter of 2015

Source: "In U.S., Uninsured Rate Dips to 11.9% in First Quarter," Gallup, Inc., April 13, 2015,

Marketplace Health Plan Enrollment

According to the J.D. Power 2015 Health Insurance Marketplace Exchange Shopper and Re-Enrollment (HIX) Study:

  • Re-enrolling in the same Marketplace plan is largely due to satisfaction with monthly premiums. More than three-fourths (78%) of re-enrollees keep their plan, while 22% switch plans primarily due to cost concerns such as monthly premiums.
  • Re-enrollees primarily use online research while shopping, particularly health plan websites (58%), followed by general online search (51%) and online consumer reviews (29%).
Source: J.D. Power

Wednesday, April 29, 2015

It’s Pharmaceutical Access, Stupid! Why Can’t Part D Plans Learn That Lesson?

By James Gutman - April 28, 2015

If it’s true that “fool me once, shame on you; fool me twice, shame on me,” then Medicare Part D plans might be feeling a lot of shame right about now. This is because even though CMS has made it super-clear that one of its highest priorities is ensuring pharmaceutical access to Part D beneficiaries, plan sponsors keep getting fined substantial amounts by the agency for violations turned up in plan audits related to access to Rx drugs.

Specifically, there have been 12 civil money penalties (CMPs) related to drug access imposed by CMS just since the beginning of the year, with all but two of them for at least six-figure amounts. The highest of those amounts for “garden variety” pharmaceutical-access violations is the $689,600 Citizens Choice Health Plan was assessed, but that’s not counting the $1 million fine CMS levied against Aetna Inc. this month for erroneously listing nearly 6,000 retail pharmacies as in network for Part D for the 2015 Annual Election Period. The apparently unintentional Aetna violations resulting from its moves to narrower pharmacy networks prompted 3,767 complaints filed by Part D plan members with CMS.

Among the other more common violations CMS has been finding in audits is failing to adjust for changes resulting from new drugs coming on the market or formerly brand drugs going generic after the Part D plans file their formularies with the agency. There are also not furnishing transition supplies of pharmaceuticals to members who change plans, using unapproved utilization-management techniques, not meeting time frames for requested coverage determinations and misclassifying complaints as coverage determinations or lumping appeals with grievances.

And it’s not that CMS hasn’t made clear that this area is a priority because of the potential for harm to beneficiaries. The agency last summer put out a “best-practices” memo outlining what it’s found in audits and saying in no uncertain terms that it’s tired of continuing to see these violations. Partly the issue is, as consultant John Gorman, executive chairman of Gorman Health Group, LLC, points out, that the Part D plans are using pharmacy benefit managers for Rx drug oversight, and some of those PBMs are still finding out what’s involved in transitioning from business-to-business to business-to-consumer organizations. There also are, as Gorman says, “lots of moving pieces” plans have to maneuver to handle drug access correctly. But as ATTAC Consulting CEO Steve Arbaugh notes, many of the problems could be avoided with some common sense, such as furnishing specific reasons for coverage denials and suggesting alternatives, along with monitoring pharmacy claim rejections and doing mock audits.

So why do you think there still apparently are so many problems for Part D plans with pharmaceutical access? Is it that the plan sponsors aren’t keeping the PBMs on a tight-enough leash? Is it that lawyers are advising plans not to furnish too much information to beneficiaries on denials? Is a big factor that making these determinations still is confusing, especially considering all the changes occurring in the Rx drug market each year? And is there one additional factor, as Gorman suggests, that “scores always get settled in the second term of a presidency” and that the Obama administration thus may find it more feasible to achieve its policy goals on pharmaceutical access via regulation than via legislation?

Today's Datapoint

$1.5 billion is the valuation earned by the privately backed New York start-up insurer Oscar Health, which is based in NYC but has national plans to sell coverage from a consumer website designed mostly for individuals on public exchanges.

Quote of the Day

 top three PBMs "have somewhat different value propositions. Express Scripts operates independently of retail providers and health plans, CVS/Caremark can provide product and pharmacy services through its owned retail pharmacy network, and Optum Rx can coordinate pharmacy services with its health plan parent when a payer client contracts with both. While all three own and operate specialty pharmacies, their corporate family affiliations — or lack of them — yield differences in how specialty pharmacy is received and perceived.... OptumRx is an important PBM, and specialty pharmacy, primarily due to its relationship to UnitedHealthcare. But at its current size and market share, it does not lead either sector — disadvantages that the acquisition of Catamaran corrects."

— Elan Rubinstein, Pharm. D., principal at EB Rubinstein Associates, told AIS's Specialty Pharmacy News.

5 Things To Know About The Latest Supreme Court Challenge To Health Law

1.    This case doesn't challenge the constitutionality of the health law

2.    If the court rules against the Obama administration, millions of people could be forced to give up their insurance

3.    A ruling against the Obama administration could have other effects

4.    Consumers could lose subsidies almost immediately

5.    Congress could make the entire issue go away by passing a one-page bill

Source: NPR

Seven tasks that help prevent hospital readmissions

1.    Medication Management

2.    Transition Planning

3.    Patient and Family Engagement/Education

4.    Information Transfer

5.    Follow–Up Care

6.    Health Care Provider Engagement

7.    Shared Accountability across Providers and Organizations

Source: Ashland Daily Tidings, March 30, 2015

The Top 10 New and Emerging Health Technology Watch List: 2015

1.    Andexanet alfa - for bleeding episodes

2.    Electrically stimulated underwear - for pressure ulcers

3.    Eravacycline antibiotic for multidrug - resistant infections

4.    Medication LCZ696 - for heart failure

5.    Nivolumab - for melanoma

6.    Molecular breast imaging system

7.     Pediatric vision scanner - for detection of strabismus and amblyopia

8.    Remote monitoring - of cardiac devices

9.    Secukinumab - for psoriasis

10.  Toraymyxin - for sepsis

Source: Canadian Network for Environmental Scanning in Health

Top 10 Most Environmentally Friendly Hospitals in the World

1.    Children’s Hospital of Pittsburgh – Pittsburgh, Pennsylvania

2.    Dell Children’s Medical Center of Central Texas – Austin, Texas

3.    Providence Newberg Medical Center – Newberg, Oregon

4.    Kiowa County Memorial Hospital – Greensburg, Kansas

5.    NewYork-Presbyterian Hospital: Vivian and Seymour Milstein Family Heart Center - NY

6.     Legacy Salmon Creek Medical Center – Vancouver, Washington

7.    West Kendall Baptist Hospital – Miami, Florida

8.    North Shore University Hospital: Katz Women’s Hospital – Manhasset, New York

9.    Muskogee Community Hospital – Muskogee, Oklahoma

10.  St. Mary’s Hospital – Sechelt, Canada


Top 5 Reasons for Visits to Retail Clinics

1.    Vaccination 74.0%

2.    Cold/Flu 55.0%

3.    Headache 23.3%

4.    Earache 13.4%

5.    Physical 18.0%

Source: Kalorama Information via PR Newswire

How Retail Clinics Can Enable the Health of Communities

1.    Integrating into the Delivery System

2.    Providing and Measuring the Quality of the Care

3.    Improving Access in Underserved Communities

4.    Providing Services to Young Children

5.    Workforce

6.    Telehealth

7.    Supporting Public Health Initiatives

8.    Remote monitoring - of cardiac devices

9.    Broadening and Bundling Services

10.  Giving New Meaning to One-Stop Shopping

Source: Robert Wood Johnson Foundation

Total Clinics For Top Convenient Care Clinic Operators

1.    CVS (Minute Clinic)- More than 800 locations across 28 states and the District of Columbia

2.    Walgreens (Healthcare Clinic)- There are approximately 400 Healthcare Clinic locations

3.    Kroger, Fry’s and King Super Stores (The Little Clinic)- There are around 120 locations

4.    Target Clinic- The company operates about 70 clinics

5.    RediClinic (H-E-B)- There are at least 30 clinics

Source: Corporate websites, Dallas Morning News

Six Things to Know from Oliver Wyman's 2015 ACO Report

1.    The 2015 total of Medicare ACOs is 426, up from 368 in January 2014 and 134 in 2013.

2.    Oliver Wyman identified an additional 159 ACOs, bringing the estimated total to 585, up 12% from 2014

3.    About 5.6 million Medicare beneficiaries (11% of total beneficiaries) now receive healthcare from ACOs

4.    These ACOs also provide care to 35 million non-Medicare patients, up 6% from 2014

5.    ACOs collectively serve between 49 and 59 million in the US,(between 15 - 17% of the population)

6.    70% of U.S. population now lives in localities served by ACOs, and 44% in areas served by two or more

Source: Oliver Wyman

According to a recent survey,

According to a recent survey, the average compensation for a primary care physician is $195,000 and for specialists is $284,000.

Source: "Medscape Physician Compensation Report 2015," Medscape, April 21, 2015,

Only 47% of primary care physicians and 50% of specialists

believe that they are fairly compensated, according to a recent survey.

Source: "Medscape Physician Compensation Report 2015," Medscape, April 21, 2015, 

According to a recent report:

  • About 11% of all Medicare beneficiaries (5.6 million) receive their healthcare from Accountable Care Organizations under Medicare’s ACO programs
  • About 35 million non-Medicare patients also receive care from these ACOs
  •  Between 15% and 17% of the U.S. population (49 to 59 million) are served by ACOs

Source: "Accountable Care Organizations now serve between 15 and 17 percent of the United States, according to new research from Oliver Wyman," Oliver Wyman Press Release, April 22, 2015,

Many Uninsured Do Not Know To Report Health Insurance Status

A recent survey of uninsured, nonelderly adults by the Urban Institute Health Policy Center found that:

  • 52.3% did plan to file their 2014 taxes, 22.3% did not plan to, and 23.2% were not sure.
  • 50.0% heard some or a lot about the requirement to report coverage.
  • 18.7% heard only a little bit about the requirement to report coverage.
  • 28.8% heard nothing at all about the requirement to report coverage.

Note: Adults who refused to report whether they planned to file a 2014 tax return are not shown.
Source: Health Reform Monitoring Survey, quarter 1 2015.

Monday, April 27, 2015

Patient Perspectives on Digital Healthcare

Here are some key findings from a recently released Harris Poll Survey on public attitudes toward digital patient engagement tools:

  • 84% of people say their doctor's offices have a patient portal.
  • Adults age 55+ (61%) are more likely to access health information via patient portals than age 18-54 (45%).
  • More than one third (37%) of people who use a wearable device/fitness tracker wear it every day.
  • 78% of those using wearables over once a month want their doctors to have access to that information.
  • More than 3 in 5 adults (64%) would at least sometimes choose telehealth visits to replace in-person visits.
  • Over a quarter (27%) say they would always/often choose this option.
  • Parents with kids under 18 (76%) are more likely to choose telehealth visits than those without kids (61%).
  • 3 in 5 people would schedule doctor appointments via a patient portal or secure website, if it was available.
Source: eClinicalWorks, April 6, 2015

Physician Perspectives on Healthcare IT

Here are some key findings from a recently released Accenture Survey on physician attitudes toward and usage of digital healthcare tools:

  • 79% of U.S. doctors are more proficient using EMR than they were two years ago.
  • The number of doctors who use digital tools has increased from 13% to 30% since 2012.
  • Over two-thirds of doctors believe that healthcare IT has decreased the amount of time spent with patients.
  • 76% of doctors believe that interoperability of the IT tools limits their ability to improve patient care quality.
  • 9 of 10 believe better functionality and easy-to-use systems are important for improving patient care quality.
  • 58% said that the electronic health record system in their organization is hard to use.
  • Those who believe EMR has improved treatment decisions decreased from 62% to 46% since 2012.
  • Fewer physicians believe EMR reduced medical errors (64 vs. 72% in 2012).
  • 46% believe EMR improved health outcomes for patients compared to 58% in 2012.
Source: Accenture, April 13, 2015

Michael Botticelli

“Michael Botticelli, the director of the White House Office of National Drug Control Policy, informally known as the drug the first person in substance-abuse recovery to hold the position.”

(Alan Schwarz, The New York Times)


“Many House conservatives backed the budget last month and spared GOP leaders another showdown with their right flank for one big reason: They were under the impression the spending blueprint would help them — finally — get an Obamacare repeal to the president’s desk….Conservatives are adamant that used to pass a repeal of the health care law. They believed GOP leaders were on board. But as House and Senate lawmakers have met to hash out a compromise budget over the past few weeks, conservatives noted that House Republican leaders have been talking about leaving their options open.”

(Rachael Bade, Politico)