Wednesday, December 30, 2015

60% of consumers have never discussed ...

...the price of a procedure with their physician, according to a recent report.

Source: "Top health industry issues of 2016," PwC, based on HRI Consumer Survey, December 2015,

Health Insurance Marketplace Open Enrollment Snapshot - Week 8 December 20 – December 26, 2015

Since Open Enrollment began on November 1, more than 8.5 million consumers signed-up for health coverage through the platform or had their coverage automatically renewed. Of the about 6 million Marketplace consumers whose coverage was renewed, about 3.6 million actively renewed and 2.4 million consumers were automatically renewed.

“As 2015 comes to an end, I am encouraged to see Marketplace consumers showing how engaged they are with their health coverage,” said Department of Health and Human Services Secretary Sylvia Burwell. "Millions of consumers that had 2015 coverage – an impressive 60 percent -- came back to to update their information, explore the options available for 2016 and select the plan that best fits their needs.  As we kick off the New Year and begin counting down to the final enrollment deadline on January 31, we will continue working to help more families learn about their options and sign up for coverage."

Similar to last year, each week, the Centers for Medicare and Medicaid Services (CMS) will release weekly Open Enrollment snapshots for the platform, which is used by the Federally-facilitated Marketplaces and State Partnership Marketplaces, as well as some State-based Marketplaces. These snapshots provide point-in-time estimates of weekly plan selections, call center activity and visits to or The final number of plan selections associated with enrollment activity to date could fluctuate as plan changes or cancellations occur, such as in response to life changes like starting a new job or getting married. In addition, the weekly snapshot only looks at plan selections and does not include the number of consumers who paid their premiums to effectuate their enrollment.

HHS will produce more detailed reports that look at plan selections across the Federally-facilitated Marketplace and State-based Marketplaces later in the Open Enrollment period. Consistent with last year’s weekly snapshots, since re-enrollment is almost entirely completed, this snapshot will be the last one during Open Enrollment 2016 that breaks out plan selections by new and renewing consumers.

Definitions and details on the data are included in the glossary.

Federal Marketplace Snapshot

Federal Marketplace Snapshot
Week 8
Dec 20  – Dec 26
Nov 1 – Dec 26
Plan Selections (net)
New Consumers
27 percent
29 percent
Consumers Renewing Coverage
73 percent
71 percent
Applications Submitted (Number of Consumers)
Call Center Volume
Average Call Center Wait Time
45 seconds
12 minutes 50 seconds
Calls with Spanish Speaking Representative
Average Wait for Spanish Speaking Rep
6 seconds
23 seconds Users
18,667,432 Users
Window Shopping Users
Window Shopping Users
133,778 State-by-State Snapshot

Consumers across the country continued to explore their health insurance options by reaching out to a call center representative at 1-800-318-2596, attending enrollment events in their local communities, or visiting or Individual plan selections for the states using the platform include:

Week 8
Nov 1 – Dec 26
New Hampshire
New Jersey
New Mexico
North Carolina
North Dakota
South Carolina
South Dakota
West Virginia


Plan Selections:  The weekly and cumulative metrics provide a preliminary total of those who have submitted an application and selected a plan. Each week’s plan selections reflect the total number of plan selections for the week and cumulatively from the beginning of Open Enrollment to the end of the reporting period, net of any cancellations from a consumer or cancellations from an insurer during that time.

Because of further automation in communication with issuers, the number of net plan selections reported this year account for issuer-initiated plan cancellations that occur before the end of Open Enrollment for reasons such as non-payment of premiums. This change will result in a larger number of cancellations being accounted for during Open Enrollment than last year. Last year, these cancellations were reflected only in reports on effectuated enrollment after the end of Open Enrollment. As a result, there may also be a smaller difference this year between plan selections at the end of Open Enrollment and subsequent effectuated enrollment, although some difference will remain because plan cancellations related to non-payment of premium will frequently occur after the end of Open Enrollment.

Plan selections will include those consumers who are automatically re-enrolled into their current plan or another plan with similar benefits, which occurs at the end of December.

To have their coverage effectuated, consumers generally need to pay their first month’s health plan premium. This release does not include totals for effectuated enrollments.

New Consumers: A consumer is considered to be a new consumer if they did not have Marketplace coverage at the start of Open Enrollment.

Renewing Consumers: A consumer is considered to be a renewing consumer if they had 2015 Marketplace coverage at the start of Open Enrollment and either actively select the same plan or a new plan for 2016 or are automatically re-enrolled into their current plan or another plan, which occurs at the end of December.

Marketplace: Generally, references to the Health Insurance Marketplace in this report refer to 38 states that use the platform. The states using the platform are Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Illinois, Indiana, Iowa, Kansas, Louisiana, Maine, Michigan, Mississippi, Missouri, Montana, Nebraska, New Hampshire, New Jersey, Nevada, New Mexico, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. States: The 38 states that use the platform for the 2016 benefit year, including the Federally-facilitated Marketplace, State Partnership Marketplaces and State-based Marketplaces.

Applications Submitted:  This includes a consumer who is on a completed and submitted application or who, through the automatic re-enrollment process, which occurs at the end of December, had an application submitted to a Marketplace using the platform. If determined eligible for Marketplace coverage, a new consumer still needs to pick a health plan (i.e., plan selection) and pay their premium to get covered (i.e., effectuated enrollment). Because families can submit a single application, this figure tallies the total number of people on a submitted application (rather than the total number of submitted applications).

Call Center Volume:  The total number of calls received by the Federally-facilitated Marketplace call center over the course of the week covered by the snapshot or from the start of Open Enrollment. Calls with Spanish speaking representatives are not included.

Calls with Spanish Speaking Representative:  The total number of calls received by the Federally-facilitated Marketplace call center where consumers chose to speak with a Spanish-speaking representative. These calls are not included within the Call Center Volume metric.

Average Call Center Wait Time: The average amount of time a consumer waited before reaching a customer service representative. The cumulative total averages wait time over the course of the extended time period. or Users: These user metrics total how many unique users viewed or interacted with or , respectively, over the course of a specific date range. For cumulative totals, a separate report is run for the entire Open Enrollment period to minimize users being counted more than once during that longer range of time and to provide a more accurate estimate of unique users. Depending on an individual’s browser settings and browsing habits, a visitor may be counted as a unique user more than once.
Window Shopping Users or Users: These user metrics total how many unique users interacted with the window-shopping tool at or, respectively, over the course of a specific date range. For cumulative totals, a separate report is run for the entire Open Enrollment period to minimize users being counted more than once during that longer range of time and to provide a more accurate estimate of unique users. Depending on an individual’s browser settings and browsing habits, a visitor may be counted as a unique user more than once. Users who window-shopped are also included in the total or user total. 

Improving the submission of quality data to CMS quality reporting programs


December 30, 2015

By Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS


Improving the submission of quality data to CMS quality reporting programs


At the Centers for Medicare & Medicaid Services (CMS), we are working to build a health care delivery system that is better, smarter and healthier – a system that delivers improved care, spends health care dollars more wisely, and supports healthier communities. The use of health information technology (IT), such as electronic health records (EHR), and data are critical pieces in building this health care delivery system. Importantly, health IT can also support electronic clinical quality measurement, which allows for more timely access to richer clinical data sources, more rapid feedback for quality improvement, and reduced reporting burden for providers.


CMS and the Office of the National Coordinator for Health Information Technology (ONC) are committed to ensuring health IT systems can support accurate, reliable, and robust reporting of quality measures. To help achieve that goal, CMS, in partnership with ONC, issued a Request for Information (RFI) today entitled Certification Frequency and Requirements for the Reporting of Quality Measures under CMS Programs, available at   The RFI provides CMS and ONC with an opportunity to assess policy options that could improve the effectiveness of the certification of health IT and specifically the certification and testing of EHR products used for the reporting of quality measures. We aim to streamline/reduce provider, hospital, and health IT developer burden.


CMS and ONC request feedback on how often to require recertification, the number of clinical quality measures to which a certified Health IT Module should be certified, and ways to improve testing of certified Health IT Module(s). The feedback received will inform CMS and ONC of elements that may need to be considered for certification and testing policies and other policies relating to the use of health IT to report quality measures that may be included in the upcoming rulemaking process for CMS quality programs.


We are working diligently to improve the means for information exchange and electronic data sharing across and among providers and health systems, increase opportunities for stakeholders to provide feedback, and enhance mechanisms for the capturing of clinical information in EHRs, registries, and other systems to assist with quality reporting and care coordination. 

The RFI has a 30-day comment period. Please review the RFI for instructions on how to submit comments. We want to hear from you and value all input received from our stakeholders.  

26% ...

... of all carriers selling coverage through state and federal public exchanges are provider-sponsored health plans, according to AIS's analysis of data in its Health Insurance Exchange Database.

"For many decades, federal policy has sought to strike the right balance...

... between maintaining the incentives needed to promote for innovation and the development of new drugs, and keeping medicines affordable. That balance...never anticipated companies acquiring off-patent drugs and then jacking up their prices to enormous heights and doing so, as one executive essentially put it, 'because I can,' but that is exactly what we have seen in recent months."

— Sen. Susan Collins (R-Maine), who chairs the Senate Special Committee on Aging, said at a Dec. 9 hearing of the committee.

Tuesday, December 29, 2015

26% ...

... of 487 large U.S. employers surveyed are addressing specialty drug cost and utilization in their medical benefit, in addition to the tactics they employ on the pharmacy side, according to the 20th Annual Towers Watson/National Business Group on Health Best Practices in Health Care Employer Survey. Specifically, 53% of employers have added new coverage and utilization restrictions for specialty pharmacy, and another 32% expect to add restrictions by 2018.

"This is a whole new provision related to the termination ...

[by HHS] of agents [operating on]. It is unwarranted, unjustified and unnecessary. At first glance, it seems that this [provision] is a good thing because it protects consumers. But when you read through the details, it is alarming. We don't defend any agents who might attempt to defraud customers...but the language used here is likely unconstitutional [because it lacks due process]. The words on the page matter."

— Wes Bissett, vice president of state government affairs at the Independent Insurance Agents and Brokers of America, commenting to AIS's Inside Health Insurance Exchanges on an HHS proposal released Nov. 20, under which brokers and agents could be barred from for 90 days if HHS suspects fraud or abuse.

According to a recent study:

  • 83% of physicians reported that at least 1% of parents refused one or more infant vaccines in a typical month
  • 20% reported that at least 5% of parents refused one or more vaccines
  • 51% of physicians (64% of pediatricians and 29% of family physicians) reported always/often requiring parents to sign a form if they refused vaccine(s)
  • 21% of pediatricians and 4% of family physicians reported always/often dismissing families if they refused at least one vaccine

Source: "Characteristics of Physicians Who Dismiss Families for Refusing Vaccines," Pediatrics, October 2015,

Cardiovascular Diseases Claimed 801,000 U.S. Lives in 2013

The American Heart Association recently released a report regarding heart disease and stroke statistics for 2013. Here are some key findings from the analysis:

·         Cardiovascular diseases claimed 801,000 lives in the U.S. in 2013.

·         1 in 3 deaths in the U.S. in 2013 were from heart disease, stroke and other cardiovascular diseases.

·         116,000 of the 750,000 people in the U.S. who had a heart attack in 2013 died.

·         In 2013, 795,000 people had a stroke, the leading preventable cause of disability.

·         Among African-Americans adults, 48% of women and 46% of men have cardiovascular disease.

·         African-Americans have nearly twice the risk for a first-ever stroke than whites.

Source: American Heart Association, December 16, 2015

CMS Finalizes Rule Creating Prior Authorization Process for Certain Durable Medical Equipment, Prosthetics, Orthotics and Supplies Items

The Centers for Medicare & Medicaid Services (CMS) today issued a final rule that would establish a prior authorization process for certain durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items that are frequently subject to unnecessary utilization. This prior authorization process will help ensure that certain DMEPOS items are provided consistent with Medicare coverage, coding, and payment rules.  CMS believes the final rule will prevent unnecessary utilization while safeguarding beneficiaries’ access to medically necessary care.  

Under the final rule, the prior authorization process will require the same information necessary to support Medicare payment today, just earlier in the process.  It will not create new clinical documentation requirements. The prior authorization process assures that all relevant coverage, coding, and clinical documentation requirements are met before the item is furnished to the beneficiary and before the claim is submitted for payment. This helps ensure that beneficiaries are not held responsible for the cost of items that are not eligible for Medicare payment. CMS believes prior authorization is an effective way to reduce or prevent questionable billing practices and improper payments for DMEPOS items.  Access is preserved in this rule by having both specified timeframes for review and approval of requests, and an expedited process in cases where delays jeopardize the health of beneficiaries.   

CMS has had longstanding concerns about the improper payments related to DMEPOS items.  The Department of Health and Human Services’ Office of the Inspector General and the U.S. Government Accountability Office have published multiple reports indicating questionable billing practices by suppliers, inappropriate Medicare payments, and questionable utilization of DMEPOS items. CMS has addressed these issues in recent years through the implementation of the DMEPOS Competitive Bidding Program, as well as heightened screening of suppliers, as authorized by the Affordable Care Act.

In addition to those actions, CMS recently expanded a 3-year prior authorization demonstration program for power mobility devices (PMDs). The demonstration began in 2012 in 7 states with high incidences of fraudulent claims and improper payments. In 2014, the demonstration was expanded to 12 additional states. Based on claims processed from September 1, 2012 through August 14, 2015, monthly expenditures for the PMD codes included in the demonstration decreased from: $12 million to $3 million in June 2015 in the original 7 demonstration states; $10 million in September 2012 to $2 million in June 2015 in the 12 additional expansion states; and $10 million in September 2012 to $3 million in June 2015 in the non-demonstration states. CMS believes the decrease in spending is due in part to national DMEPOS suppliers adjusting their billing practices nationwide (not just in the demonstration states) to comply with CMS policies based on their experiences with prior authorization in the demonstration states.

This final rule further addresses questionable utilization and improper payments by creating a prior authorization process for certain DMEPOS items beyond PMDs.  Under Section 1834(a)(15) of the Social Security Act, the Secretary has the authority to develop and periodically update a list of DMEPOS items that the Secretary determines, on the basis of prior payment experience, are frequently subject to unnecessary utilization and to develop a prior authorization process for these items. The final rule implements this authority by creating:  a “Master List” of items that meet specific criteria and are potentially subject to prior authorization; a “Required Prior Authorization List,” a subset of items on the Master List; and a prior authorization program for the Required Prior Authorization List items.

The Master List is the set of 135 DMEPOS items identified as being frequently subject to unnecessary utilization.  Items that meet the following criteria are included on the Master List and thus potentially subject to prior authorization: items on the DMEPOS Fee Schedule with an average purchase fee of $1,000 or greater, or an average rental fee schedule of $100 or greater, (adjusted annually for inflation) and the subject of:

  • HHS Office of the Inspector General (OIG) or U.S. Government Accountability Office (GAO) reports that are national in scope and published since 2007, or
  • Comprehensive Error Rate Testing Annual Medicare Fee-for-Service Improper Payment Report Durable Medical Equipment (DME and/or) Report’s DMEPOS Service Specific Reports.

The list is self-updating annually such that items on the DMEPOS Fee Schedule that meet the payment threshold are added to the list when the item is the subject of an OIG or GAO report of a national scope or a future CERT DME Service Specific Report. Items will remain on the list for 10 years, but can be removed sooner if the purchase amount drops below the payment threshold.  After 10 years, items can remain on the list or be added back to the list if a subsequent report identifies the item as frequently subject to unnecessary utilization.

Presence on the Master List does not automatically create a prior authorization requirement for that item. In order to balance minimizing provider and supplier burden with protecting the Medicare Trust Funds and beneficiary access, CMS will initially implement prior authorization for a subset of items on the Master List (referred to as “Required Prior Authorization List”). CMS will publish the Required Prior Authorization List in the Federal Register with 60-days’ notice before implementation of prior authorization for those items.

Prior authorization will be required for those DMEPOS items on the Required Prior Authorization List.  The process requires all relevant documentation to be submitted for review prior to furnishing the item to the beneficiary and submitting the claim for processing. CMS or its contractors will review the prior authorization request and provide a provisional affirmation or non-affirmation decision.  A claim submitted with a provisional affirmation decision will be paid so long as all other requirements are met.  A claim submitted with a non-affirmation decision or without a decision will be denied.  Unlimited resubmissions of prior authorization requests are allowed.  

Medicare or its review contractor will make a reasonable effort to render an initial prior authorization determination within 10 business days and will make a reasonable effort to render a resubmission prior authorization determination within 20 business days.  These are maximum timeframes and will be adjusted downward for items that require less time for making a determination.  An expedited review process will be available to address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary. The request for an expedited review must provide rationale supporting the request.

CMS will issue specific prior authorization guidance in subregulatory communications.

The final rule is currently on display at   

Monday, December 28, 2015

53% of consumers would be willing to pay the cost of a drug ...

... over time instead of all at once, while 17% would not, according to a recent report.

Source: "Top health industry issues of 2016," PwC, based on HRI Consumer Survey, December 2015,

67% are Satisfied with Their Personal Healthcare

Booz Allen Hamilton and Ipsos Public Affairs recently released a report regarding consumer and provider perspectives on American healthcare. Here are some key findings from the analysis:

·         67% of consumers are currently satisfied with their personal healthcare.

·         43% of administrators believe that the healthcare system is headed in the right direction.

·         Most (83%) physicians think doctors are losing autonomy, while half of administrators share that view.

·         1 in 2 consumers say that better care coordination between providers can have an impact on healthcare.

·         29% of consumers use a mobile app or personalized interactive website to monitor or manage their health.

·         Almost 3 in 5 consumers approve of their doctors sharing their health information to better manage care.

Source: Booz Allen Hamilton, December 17, 2015

Medicare Drug Spending Dashboard



To view the Medicare Drug Spending Dashboard, visit:


December 21, 2015

By Andy Slavitt, Acting CMS Administrator and Niall Brennan, CMS Chief Data Officer


Medicare Drug Spending Dashboard

Just over a month ago, HHS convened a forum that brought together consumers, providers, employers, manufacturers, health insurance companies, representatives from state and federal government, and other stakeholders to discuss ideas on how our country can meet the dual imperatives of encouraging drug development and innovation, while ensuring access and affordability. The conversation touched on many ideas to increase access to information, promote value, drive innovation, strengthen incentives and promote competition.

Today, CMS is releasing a new online dashboard to provide information on Medicare spending on prescription drugs, for both Part B (drugs administered in doctors’ offices and other outpatient settings) and Part D (drugs patients administer themselves) to provide additional information and   increase transparency.  Having this information available to the public in an accessible format should inform health care decisions, policy considerations and encourage collective problem solving around these important issues.

This interactive dashboard allows consumers, policy makers, academics, manufacturers, purchasers, consumers, and other stakeholders to see six lists, comprising 80 drugs -- three lists for Medicare Part B and three for Medicare Part D, sorted by the:

  • Top 15 drugs by total annual cost,
  • Top 15 drugs by the highest spending per Medicare user, and
  • Top 10 drugs with the highest annual increase in cost in 2014.

The dashboard includes information on each prescription drug, including cost trend analysis, brand names, generics, and the name of the manufacturer, and provides easily searchable, detailed information and data.  The 80 prescription drugs included in the dashboard represent 33 percent of all Part D spending and 71 percent of Part B drug spending in 2014, or $55 billion of the more than $143 billion in Medicare prescription drug spending in 2014. Prescription drug spending in Parts B and D was 14 percent of total Medicare spending in 2014, up from 11 percent in 2010 – just five years ago. 

In today’s announcement, the topline findings include:

  • The diversity, growth, and impact of drug spending in the Medicare program – while the high-cost drugs include brand name Hepatitis C and cancer therapies, some generic drugs are seeing large price increases.
  • The trends of how drug spending change and shift over time - for the Medicare program, its beneficiaries, manufacturers and by condition.

Other insights include:

  • The five Medicare Part D drugs with highest total drug spending each accounted for more than $2 billion in spending in Part D in 2014 and more than $1 billion in Part D in 2013.
  • The highest increase in spending per unit in Part D was 500 percent and in Part B it was 78 percent.
  • The highest cost per user in Part D is Sovaldi at $94,056 and for Part B is Remodulin at $133,845 per user in 2014.

Our Larger Goal: Broader Data Availability

The Medicare dashboard, of course, is only part of the story. While it will help answer some questions, we acknowledge that there are other questions it does not answer:

  • The dashboard does not provide the net prices paid to manufacturers or the rebates to plans and prescription benefit managers. In the Part D program, we are not permitted to disclose the rebates paid by manufacturers to Part D plan sponsors. And for Part B, Medicare does not receive a rebate, but pays 106 percent of the estimated average sales price of each drug, which reflects the average prices paid by physician offices and hospital outpatient departments net of discounts and rebates.
  • The dashboard includes average cost sharing information, but does not show what any particular beneficiary will pay, as the latter would require information on formulary tiering, co-payments, and mail-order preferences from Part D pharmacy benefit managers (PBMs) and health plans. Likewise, in Part B providers can increase cost sharing of the drug, and information on those increases isn’t widely available.
  • The dashboard does not show spending for other payers like commercial purchasers, Medicaid, or other federal purchasers like the Veterans Administration or the Department of Defense.

Most importantly, the dashboard doesn't provide information on the clinical or financial value of the drug. While the dashboard describes the therapeutic uses, these data do not capture the value these drugs can have on managing chronic disease or improving or extending quality of life for patients. For instance, the Hepatitis C drugs presented in this dashboard are an example of where spending has increased dramatically, but have brought about a major shift from the standard of care that previously existed for Hepatitis C patients.

We realize the dashboard doesn't provide a complete picture, but still believe that, by sharing this information and allowing people to analyze the data, we can increase the knowledge around drug spending and support efforts that are evaluating whether public dollars are being spent most effectively. The drugs included in dashboard are likely to have an impact on spending and should spur public discussion of how these products are affecting the Medicare program.

We also seek to stimulate the release of additional data that will promote a more complete understanding of value and patient affordability. We believe that there is complementary data now available from other entities on rebates, clinical effectiveness, pharmacoeconomics, comparative effectiveness, safety, formulary placement and discounts on these drugs, including the Agency for Healthcare Research and Quality’s (AHRQ) EPC Evidence Based Reports. Our hope is that over time outside parties will release this type of information in order to broaden the understanding of these drugs. 

CMS's Commitment and Responsibility to Data Availability

 Over the past several years, CMS has made it a priority to make more data available including, publishing extensive information on utilization and payments in the Medicare program. Starting in 2013, we published data on inpatient and outpatient hospital discharges by individual. We also started releasing payment and utilization data on the services and procedures provided to Medicare beneficiaries by physicians and other suppliers in 2014. Since then, we have also released similar information on the prescribing behaviors of physicians and other healthcare professionals as well as information on those who ordered durable medical equipment, prosthetics, orthotics and supplies items and services. Today’s release is part of that larger effort.

We are committed, as we always are when we publish data, to receiving input to make sure the data are accurate, fairly presented, constructive, and shown in a way that protect the identity of beneficiaries.  Physicians, pharmacists, patients, manufacturers, researchers, and others are encouraged to provide us with feedback to inform our understanding of these data and make sure they are presented appropriately. If you have ideas on what other data would be useful for the federal government or the private sector to release that increases visibility into the economics of drug pricing and are relevant to better health decision-making, please email us at

Today, we take an important step forward in improving understanding and expanding the dialogue around the topic of prescription drug costs. We at CMS look forward to continuing this work in partnership with stakeholders to find ways to continue to improve the affordability and accessibility of life-saving prescription medications for beneficiaries in Medicare, Medicaid, and other health insurance programs.