Tuesday, May 31, 2016

State Campaign Focuses on Protection Against Zika

A new campaign from the Texas Department of State Health Services reinforces what people can do to “not give Zika a biting chance” this summer. The campaign, which launches today, features public service announcements on radio and television along with online and outdoor ads reminding people they should prevent Zika by removing standing water, keeping mosquitoes out of their homes and preventing mosquito bites.

Sample ads and other materials are available at www.texaszika.org/materials.htm.

Everyone will benefit from following the advice because the same precautions help prevent other illnesses transmitted by mosquitoes, such as West Nile virus and chikungunya. The campaign also aims to reach groups for whom the precautions are particularly important.

Travelers to and from Latin America, the Caribbean and other areas with ongoing Zika transmission play a major role in helping stop the spread of the virus. There have been no documented cases transmitted by mosquitoes in Texas and no evidence that Texas mosquitoes are infected. If travelers protect themselves while abroad and for 21 days after returning to Texas, they can delay or prevent Zika from being introduced into the state.

The campaign also seeks to reach pregnant women because while Zika virus disease, itself, is usually mild, Zika can cause serious birth defects if a woman is infected during pregnancy. Pregnant women should delay travel to Zika hot spots and should avoid acquiring the virus from sexual partners who have traveled abroad.

The total value of the campaign is $2 million and is funded by federal public health emergency preparedness funds.

Zika virus is transmitted to people primarily through the bite of an infected mosquito, though sexual transmission from an infected person is possible. Texas has had 36 travel related cases in the last several months.


(News Media Contact: Chris Van Deusen, DSHS Press Officer, 512-776-7753)

This service is provided to you at no charge by the Texas Department of State Health Services.

Visit us on the web at http://www.dshs.state.tx.us/.

Medicare’s “Big Data” Tools Fight & Prevent Fraud to Yield Over $1.5 Billion in Savings

May 27, 2016
By Dr. Shantanu Agrawal, Raymond Wedgeworth and Kelly D. Bowman 

Medicare’s “Big Data” Tools Fight & Prevent Fraud to Yield Over $1.5 Billion in SavingsIn 2015, National ROI of $11.60 for Each Federal Dollar Spent 

A version of this commentary was published in May 24 editions of Modern Healthcare. New anecdotal content has been added. Please see the following link to view the original content – http://www.modernhealthcare.com/article/20160524/NEWS/160529960/commentary-medicares-big-data-tools-to-fight-and-prevent-fraud-yield

Over the past five years, the CMS has successfully implemented a Fraud Prevention System using “big data” and predictive analytics approaches to fight fraud, waste and abuse in the Medicare fee-for-service program.

Taking “big data” mainstream has given the CMS the ability to better connect with public and private predictive analytics experts and data scientists, as well as collaborate more closely with law enforcement. The Fraud Prevention System's “big data” effort has had a profound impact on fraudulent providers and illegitimate payments by allowing us to quickly identify issues and take action. 

For example, the FPS identified a home health agency in Florida that billed for services that were never rendered.  Due to the FPS, CMS placed the home health agency on prepayment review and payment suspension, referred the agency to law enforcement, and ultimately revoked the agency’s Medicare enrollment. In Texas, FPS identified an ambulance company submitting claims for non-covered services and services that were not rendered.  Medicare revoked the ambulance company’s enrollment.  Likewise, FPS identified that an Arizona, medical clinic had questionable billing practices, such as billing excessive units of services per beneficiary per visit.  Upon review of medical records, it was discovered that physicians had been delivering repeated and unnecessary neuropathy treatments to beneficiaries. The medical clinic was revoked in 2015 from Medicare enrollment. 

Through cases like these, the CMS is seeing impressive results nationwide. This predictive analytics technology contributed to more than $1 billion in savings in 2014 and 2015.

The Fraud Prevention System, or FPS, is innovative in that we have moved beyond the reactive “pay and chase” approach toward a more effective, proactive strategy that aims to prevent these illegitimate payments in the first place. Since its June 2011 inception, the FPS has identified significant savings by running sophisticated analytics on 4.5 million Medicare claims on a daily basis, prior to payment. Year after year, the FPS has continued to improve its ability to identify or prevent fraud. Since the beginning of the program, over $1.5 billion in inappropriate payments has been identified by the system through new leads or contributions to existing investigations. Also, in 2015, the CMS marked its first-ever national return-on-investment of $11.60 for every dollar the federal government spends on this program integrity system.

As we moved toward preventing inappropriate payments, we also successfully developed ways to measure costs avoided due to removing certain providers from the Medicare program and tracking return on investment. These methodologies to calculate cost avoidance have achieved certification by HHS' Office of Inspector General, the first such certification in the history of federal healthcare programs.

The CMS is now working to develop next-generation predictive analytics with a new system design that even further improves the usability and efficiency of the FPS. Using it and other advanced tools, we are committed to addressing fraud, waste and abuse in the Medicare program to better protect beneficiaries and taxpayers.

DSHS Announces First Texas-Acquired Chikungunya Case

Recently reported case contracted in 2015

The Texas Department of State Health Services has confirmed the first locally acquired case of chikungunya, a mosquito borne illness. A Cameron County resident got sick with the illness in November 2015 and was diagnosed with a lab test in January 2016. The case, however, was not reported to the local health department until last month. The investigation performed by the Cameron County Department of Health and Human Services determined the patient had not traveled, and the case was confirmed last week by testing at the US Centers for Disease Control and Prevention.

Chikungunya disease is a viral illness spread by mosquitoes and was first detected in travelers returning to Texas from areas with local transmission in 2014. All previous Texas residents who contracted the illness were infected while traveling abroad. Because this case was contracted more than six months ago and mosquito surveillance has not found chikungunya in local mosquitoes, the primary risk of infection remains related to travel. DSHS encourages people to protect themselves from mosquito bites at home and while traveling to stop the spread of chikungunya, Zika and West Nile virus.

Chikungunya and most other viruses transmitted by mosquitoes are required to be reported to the local health department or DSHS regional office within one week. DSHS reminds laboratories and health care providers to report cases promptly so health officials will have the information they need to make decisions that will protect public health.

Chikungunya illness is rarely fatal but can cause severe joint pain, high fever, head and muscle aches, joint swelling and rash. Most people feel better within a week, though some may develop longer-term joint pain.


(News Media Contact: Chris Van Deusen, DSHS Press Officer, 512-776-7753)

This service is provided to you at no charge by the Texas Department of State Health Services.

Visit us on the web at http://www.dshs.state.tx.us/.

According to a recent Gallup survey of U.S. adults...

... regarding three different scenarios for the future of health care:

  • 48% favored keeping the Affordable Care Act as it is, with 49% opposed
  • 51% favored repealing the Affordable Care Act, with 45% opposed
  • 58% favored replacing the Affordable Care Act with a federally funded health insurance program for all Americans, with 37% opposed

Insights from the 2016 Survey of US Health Care Consumers


1.Exchange consumers say they are satisfied with their coverage at the same rate as people with employer coverage


2. More exchange consumers feel prepared to handle future costs and more able to access affordable care than last year


3.More than twice as many exchange consumers report using online information to shop for a policy than the average consumer


4.More exchange consumers understand their costs than consumers with employer coverage, and had fewer surprise out-of-pocket costs


5.Exchange consumers shop around for coverage before making decisions, and they continue to be willing to accept network tradeoffs for lower payments



Source: Deloitte

Specialty Drugs Contributed Another $87 Annually Per Enrollee in 2014

Blue Cross Blue Shield recently conducted an analysis on the high cost of specialty drugs. Here are some key findings from the report:

·         Specialty drugs contributed another $87 annually in costs per enrollee whether or not they used them.

·         Spending on specialty drugs jumped 26% in 2014 due to new hepatitis C pills like Sovaldi.

·         Sovaldi, which was launched in 2014 by Gilead Sciences, costs $84,000 per treatment.

·         Prescription drug spending overall jumped 12.6% in 2014 and 7.6% in 2015.

·         Hepatitis spending, which grew 612% in 2014, resulted in a $29 annual increase per member.

·         Drug spending on inflammatory conditions grew by 29%, resulting in a $22 annual increase per member.

Source: Forbes, May 19, 2016

Thursday, May 26, 2016

28.6 Million People Were Uninsured in 2015

The Centers for Disease Control and Prevention recently released results from the National Health Interview Survey on health insurance coverage. Here are some key findings from the report:

·         28.6 million (9.1%) were uninsured in 2015, or 7.4 million fewer persons than in 2014.

·         Among adults aged 18-64, the percentage uninsured decreased from 16.3% in 2014 to 12.8% in 2015.

·         5.5% of children aged 0-17 years were uninsured in 2015 compared to 4.5% in 2014.

·         Among those under 65, 9.1 million had private coverage through the Marketplace or exchanges in 2015.

·         3.4% had private coverage through the Marketplace or exchanges in 2015, vs 2.5% in 2014.

·         The percentage of adults age 18-64 with private coverage increased from 67.3% to 69.7% in 2015.

Source: CDC, May 18, 2016

3 health organizations that use predictive analytics to improve patient care quality

1. Maine HealthInfoNet: Predicting and preventing ER visits

2. Carolinas HealthCare System: Using consumer data to learn about lifestyle habits

3. University of Iowa Hospitals and Clinics: Preventing post-op infections by identifying high-risk patients



According to a recent report ...

Marketplace health plans underwent the following cost-sharing changes from 2015 to 2016, on average:

  • The out-of-pocket limit rose 7.1%
  • The general annual deductible rose 10.3%
  • The copay for a primary care physician visit rose 0.4%
  • The copay for generic drugs fell 3.2%
  • The copay for preferred brand-name drugs rose 4.7%
  • The copay for non-preferred brand-name drugs rose 13.6%

The Centers for Medicare & Medicaid Services (CMS) has released a new resource that describes:

The Affordable Care Act ensures a consumer’s right to appeal health insurance plan decisions, including asking that an issuer reconsider its decision to deny payment for a service or treatment, or to rescind coverage.


The Centers for Medicare & Medicaid Services (CMS) has released a new resource that describes:

  • What issuer decisions can be appealed
  • How long consumers have to initiate appeals
  • How consumers must document and submit appeals
  • How consumers can request an expedited appeal timeline in urgent care situations
  • When and how to request an external review by state or federal authorities

These appeal rights and processes apply to consumers enrolled in non-grandfathered qualified health plans through a Health Insurance Marketplace.


Please see the “Internal Claims and Appeals and External Review Processes Overview” resource slides for more information. You can also link to these slides from the Agents and Brokers Resources webpage, which provides other resources to help you assist consumers in making use of their health coverage.


25% ...

... of the phone numbers for psychiatrists listed in network directories on Washington, D.C.'s public exchange did not work, and just 7% of listed psychiatrists were able to schedule a new appointment within two weeks, according to a new study from the American Psychiatric Association.

Wednesday, May 25, 2016

"The lenient [ACA exchange rules governing special enrollment periods] rules...

... particularly with regard to change of address, have become subject to gaming. Existing regs made it difficult for CMS to tighten the rules. With this [new reg issued by CMS on May 6 to close the loophole], CMS now will be able to address one of the primary SEP problem areas."
— Michael Adelberg, a former senior official in CMS's Center for Consumer Information and Insurance Oversight, who is now at FaegreBD Consulting, told AIS's Inside Health Insurance Exchanges

Nearly 25% ...

... of the people who purchased 2015 health coverage through a public exchange stopped paying their premiums at some point during the year, yet most repurchased an exchange plan for 2016, according to a McKinsey & Co. report.

According to a recent report, the percentage of persons under age 65 ...

... with private coverage through the Health Insurance Marketplace or state-based exchanges increased from 2.5% (6.7 million) in the fourth quarter of 2014 to 3.4% (9.1 million) in the fourth quarter of 2015.

Source: "Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2015," Centers for Disease Control and Prevention, May 2016, http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201605.pdf

Pitching Medicaid IT in Silicon Valley

CMS Blog


May 25, 2016
By Andy Slavitt, CMS Acting Administrator @aslavitt


Pitching Medicaid IT in Silicon Valley

Earlier this year, I announced a new effort to connect new, innovative companies and their investors to the state Medicaid program IT space. Since this announcement, I have been encouraged by the initial interest from companies that may not have otherwise ever thought about participating in this important health insurance program that covers more than 72 million Americans.

That’s why I’m in Silicon Valley today to participate in a forum on bringing technological advances to Medicaid. The forum is convening states, innovative tech companies, and federal Medicaid officials on how to collaborate to improve the delivery of Medicaid health coverage in states.

These meetings will help in getting two very different cultures – state government and tech companies – speaking the same language and exploring opportunities to work together to continue to improve care delivery within Medicaid. 

While there are 56 different state, district, and territorial Medicaid programs, there is a lot of commonality in their IT needs. There is always new IT procurement and opportunities for new, innovative vendors in this space. This industry is primed for a new era -- Software as a Service software– that has real time capabilities and requirements and Federal sponsorship for a 90 percent match on qualifying IT investments. 

Investment gravitates to needs and problems it can solve. There is no greater opportunity than bringing technical know-how, innovation and creativity to improve the health of Americans with health, social and economic challenges. 

CMS is fully committed financially and operationally to partner with states and the private sector to improve state programs. The federal government alone invests more than $5 billion per year in Medicaid IT and matches up to 90 percent on new projects. Still, there may be some apprehension by IT companies – large or small, new or established – to engage in bidding for state government contracts.

But, we’re working to tear down these barriers and taking it past the opportunity to make a new market. 

We’ve already created a one-stop-shop for the tech community to connect with states looking for innovative solutions. On this site, vendors can easily find links to states’ Medicaid procurement websites and to any open state Medicaid IT Requests for Proposals.

We are also doing more to bring these two groups together. CMS is developing a “playbook” to help companies translate states’ requests for proposals into work they believe can move the needle. We are also inviting vendors to seek pre-certification from CMS for their Medicaid IT solutions and put their names and products on a “Pre-Certified Medicaid Modules” list on our Medicaid.gov website.

Finally, to help be a bridge between states and the tech sector, we are actively recruiting a full time entrepreneur-in-residence fully committed to the Medicaid space.

It is an exciting time to be in the Medicaid space. With Medicaid expansion, Medicaid has become America's health plan. Medicaid has always served some of our most vulnerable citizens: the elderly, disabled, low-income, pregnant women, and children. New policies strengthen consumer access and driving improved quality and additional care options for people at home and in their communities. Stronger approaches to IT underpin these promising new directions.
This work has the potential to leave a legacy in the lives it touches for many years to come. Engaging the tech community and federal and state policy makers in this substantial modernization effort is just the beginning.

The Federally-facilitated Marketplaces (FFMs) are working with the Internal Revenue Service (IRS)...

... to confirm consumers have reconciled advanced payments of the premium tax credit (APTC) they received during plan year 2014. Consumers whom the FFMs and IRS determine have failed to complete reconciliation for 2014 could lose their current plan year APTC as soon as October 2016, and could be reenrolled in coverage for plan year 2017 without APTC.

Register now for the “IRS Data Recheck of Failure to File and Reconcile 2014 APTC Population” webinar on June 2 from 1:00 PM to 2:00 PM Eastern Time (ET) to learn more on these new rules.
To register for the webinar, please log in to www.REGTAP.info. If you have questions on the webinar registration process, visit the “Upcoming Agent and Broker Webinars” section of the Agents and Brokers Resources webpage for more information.

Tuesday, May 24, 2016

Small Critical Access Hospitals Have Fewer Post-Surgery Complications

JAMA recently published results from a study comparing rural critical access hospitals (CAHs) to larger urban hospitals. Here are some key findings from the report:

·         Mortality within 30 days of a surgery (5.5%) was the same at a critical access hospital as larger hospitals.

·         The same surgery costs Medicare $1,400 less at a critical access hospital than at a larger hospital.

·         1 in 4 patients had complications after surgery at large hospitals, while 17.5% did at CAHs.

·         5% of surgery patients at CAHs got transferred to larger hospitals, vs 25% of other patients.

·         CAH surgery patients were less likely to use skilled nursing facilities after their operations.

·         Patients undergoing surgery at critical access hospitals had lower rates of heart failure (7.7% vs 10.7%).

Source: JAMA, May 17, 2016

Rising prices drives spending growth for children's healthcare in 2014

1.Per capita spending on healthcare for children covered by employer-sponsored insurance grew an annual average of 5.1 percent per year between 2010 and 2014, reaching $2,660 in 2014


2. Out-of-pocket spending on children covered by employer-sponsored insurance increased an average annual 5.5 percent between 2012 and 2014, to $472


3.Prices fueled much of the spending growth in 2014


4.At the same time spending increased, there was a general decline in the use of healthcare services. In 2014, there were 3,228 physician visits per 1,000 children, down slightly from the previous year


5.For the study, HCCI also looked at children's healthcare spending trends at the state level in 2014


According to a recent survey:

  • 61% of health insurance exchange consumers say they take into account the total costs, not just premiums, when evaluating different coverage options
  • Almost 40% say they consider brand and total costs when evaluating their coverage options
  • 66% of health insurance exchange consumers used online tools to compare out-of-pocket costs, versus 58% of those with employer health coverage who shopped for a policy online and had access to similar tools

Source: "Public health insurance exchange enrollees: Insights from the 2016 Survey of US Health Care Consumers," Deloitte News Release, May 11, 2016, http://www2.deloitte.com/us/en/pages/life-sciences-and-health-care/articles/health-care-consumers-health-insurance-exchanges.html

Monday, May 23, 2016

54% of Small Firms Offered Health Benefits in 2015

Kaiser Family Foundation recently released an infographic on eligibility and coverage trends in employer-sponsored health insurance. Here are some key findings from the report:

·         The share of workers with employer-sponsored insurance dropped from 63% to 56% between 2000-2015.

·         Fewer than half of large firms offered coverage to same-sex or opposite-sex domestic partners.

·         In 2015, 97% large firms (>100 workers) offered health benefits, compared to 54% of small ones (3-49).

·         Among people under age 65, those with lower incomes were less likely to have health benefits.

·         5% of firms with more than 200 workers reduced hiring full time employees due to health benefit costs.

·         In 2015, firms with fewer workers 26 years or younger were more likely to offer health insurance (66%).

Source: Kaiser Family Foundation, May 3, 2016

What is the avg. cost per prescription for specialty drugs?

2015 Cost, By Condition, Of Specialty Drugs Based On Avg. Price Per Prescription


1. Hepatitis C - $17,090.18

2. Sleep Disorders - $8,928.96

3. Oncology - $7,158.53

4. Cystic Fibrosis - $6,441.27

5. Multiple Sclerosis - $4,549.22

6. Pulmonary Hypertension - $3,892.31

7. Inflammation - $3,035.95

8. HIV - $1,272,01


Notes: Mercer 2015 national survey of employer sponsored health plans & express scripts 2015 drug trend report


Source: Mercer

According to a recent government report,

... 2% of adolescents ages 10–17 did not have a usual place for preventive health care in 2014; 21% did not receive a well-child checkup, and 12% had not visited a dentist in the past 12 months.

Source: "Access and Utilization of Selected Preventive Health Services Among Adolescents Aged 10–17," Centers for Disease Control and Prevention, NCHS Data Brief No. 246, May 2016, http://www.cdc.gov/nchs/products/databriefs/db246.htm

50% Looked Up Health Information on the Internet in 2015

The Centers for Disease Control recently released results from the National Health Interview Survey on health information technology use. Here are some key findings from the report:

·         3.7% used online chat groups to learn about a health topic in the past 12 months.

·         Half of everyone surveyed looked up health information on the internet in 2015.

·         8.7% filled a prescription online in the past 12 months.

·         1 in 10 scheduled an appointment with a healthcare provider online in 2015.

·         11.2% communicated with a health provider by email in the past 12 months.

·         3 in 4 with advanced degrees looked up health information online, vs. 35% of high school graduates.

Source: CDC, May 18, 2016

Health plan operators that intend to sell individual coverage in Washington state this fall ...

... have proposed an average rate increase of 13.5%, the Office of the Commissioner of Insurance reported May 16. Thirteen carriers collectively filed 154 individual health plans for 2017 coverage to be sold inside and outside of the Washington Healthplanfinder exchange. Nine of the 13 insurers intend to sell individual plans inside the exchange, and four will sell only outside of it. Premera Blue Cross, which seeks to sell coverage only outside of the exchange, asked to boost its rates by 20%. Coordinated Care, a subsidiary of Centene Corp., is seeking the lowest percentage increase at 7.4%. UnitedHealthcare of Washington will leave the state's individual market in 2017, and Moda withdrew in January. Both insurers sold plans statewide. Two other statewide insurers, Premera and Lifewise, intend to stop marketing outside of the exchange and will reduce the number of counties where they will offer plans, according to the state's insurance commissioner.

$37 million ...

... was recently awarded to Aetna, Inc. by a California Superior Court jury when the insurer sued the Northern California surgery provider Bay Area Surgical Management LLC for allegedly defrauding Aetna via the use of out-of-network benefits.

"Alzheimer's is the only disease ...

... among the top 10 causes of death in America that cannot be prevented, cured or even slowed."

— According to the Alzheimer's Association.

Thursday, May 19, 2016

According to a recent report, here are the average 2016 ...

deductibles for Marketplace health plans that had deductibles:

  • $5,724 for bronze plans
  • $3,100 for silver plans
  • $1,257 for gold plans
  • $484 for platinum plans

Source: "New Commonwealth Fund Report: Consumer Cost-Sharing in Affordable Care Act Marketplace Plans Increased Modestly From 2015 to 2016," The Commonwealth Fund, May 12, 2016, http://www.commonwealthfund.org/publications/press-releases/2016/may/consumer-cost-sharing

Employer Responsibility For Workers In Retirement

Among large firms that offer active workers health coverage, the percentage that also offer retiree health plans has shrunk to 23% in 2015 from 66% in 1988. The decline, which has been steady and almost unbroken, almost certainly reflects the rising cost of healthcare and employers' diminishing sense of responsibility for long-term workers in retirement. 

Source: Kaiser Family Foundation

Five things to know about Medicare Advantage Enrollment Trends

1. 31% of Medicare beneficiaries are enrolled in a Medicare Advantage plan in 2016

2. Over 3 million enrollees (18%) are in a group plan in 2016.

3. UnitedHealthcare and Humana together account for 39 percent of enrollment in 2016

4. Premiums paid by enrollees were relatively constant between 2015 and 2016 ($37 per month in 2016 versus $38 per month in 2015)

5. 37% of all enrollees in Medicare Advantage prescription drug plans in 2016 are in plans with limits at the maximum.



Source: KFF

Superior Customer Experience Correlates to 50% Higher Hospital Margins

Accenture recently published an analysis on customer satisfaction from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Here are some key findings from the report:

·         Hospitals that deliver "superior" customer experience have 50% higher net margins than average hospitals.

·         The margin increase at urban hospitals is roughly eight times that of rural hospitals.

·         Academic hospitals had a 2.1% margin increase per 10% increase in HCAHPS score in 2013.

·         Margin increase correlated to a 10% consumer experience improvement grew 70% from 2008-2013.

·         Among the top 20% of patient experience performers, revenues grew 10.9% and costs grew 7.8% in 2013.

·         For profit hospitals had a 3.3% margin increase per 10% increase in HCAHPS score in 2013.

Source: Accenture, May 11, 2016

According to a recent report, the 2016 average ...

... copayment for primary care visits is $29 under Marketplace health plans and $24 under employer-based plans.

Source: "New Commonwealth Fund Report: Consumer Cost-Sharing in Affordable Care Act Marketplace Plans Increased Modestly From 2015 to 2016," The Commonwealth Fund Press Release, May 12, 2016, http://www.commonwealthfund.org/publications/press-releases/2016/may/consumer-cost-sharing

Tuesday, May 17, 2016

53% of Exchange Consumers are Satisfied With Their Health Plan

Deloitte recently published their 2016 Survey of US Health Care Consumers. Here are some key findings from the report:

·         More than half (53%) of exchange consumers are satisfied with their health plan overall.

·         54% of those with employer insurance and 74% of those with Medicare are satisfied.

·         7 in 10 exchange consumers say they had no financial difficulty paying out-of-pocket costs last year.

·         34% of exchange consumers feel prepared to handle future health care costs compared with 16% in 2015.

·         Nearly half of exchange consumers (45%) say they feel confident about being able to get affordable care.

·         67% of exchange consumers looked online for help selecting a policy vs. 30% with employer coverage.

Source: Deloitte, May 11, 2016