DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
Room 352-G
200 Independence Avenue, SW
Washington, DC 20201
Office of Media Affairs
OPEN ENROLLMENT ENDS TOMORROW; PEOPLE WITH MEDICARE SEE SIGNIFICANT SAVINGS IN 2011 AS TIME TO SELECT 2012 PLANS ENDS
Nearly three million people with Medicare receiving discounts on prescription drugs,
24.2 million receiving free preventive care
Today, the Centers for Medicare & Medicaid Services (CMS) announced that as of the end of October, more seniors and people with disabilities on Medicare have seen significantly lower costs for important health care – through both discounts on brand-name drugs in the Medicare Part D "donut hole" coverage gap and free preventive care.
“Thanks to the Affordable Care Act, millions of Americans are receiving free preventive services and getting cheaper prescription drugs,” said Acting CMS Administrator Marilyn Tavenner. “The open enrollment period ends tomorrow. People with Medicare should review their current plans before midnight December 7, so they can make sure that the plan they will have in 2012 is the best one for their health care needs.”
Data show that 2.65 million people with Medicare have saved more than $1.5 billion on their prescriptions – averaging about $569 per person.
And, as of the end of November, more than 24.2 million people with Medicare have taken advantage of at least one free preventive benefit – including the new Annual Wellness Visit – made possible by the Affordable Care Act.
Building on savings in 2011, Medicare also recently announced that the Part B deductible will be $22 lower in 2012 and average Medicare Advantage premiums are projected to drop four percent in 2012. Part B premiums, which cover outpatient services including doctor visits, are estimated to increase by only $3.50 per month for most beneficiaries in 2012, and some will see a decrease. These changes will be more than offset by the average Social Security cost of living increase ($43 per month for retired workers).
People with Medicare can now review their drug and health plan coverage options for 2012 as part of the annual Medicare Open Enrollment Period. CMS is highlighting plans that have achieved an overall quality rating of five stars with a high performer or “gold star” icon on Medicare’s Plan Finder – www.medicare.gov/find-a-plan.
For more information about how the Affordable Care Act closes the donut hole over time, go to: http://www.medicare.gov/Publications/Pubs/pdf/11493.pdf
For State-by-State information on the number of people who are benefiting from discounts in the donut hole in 2011, go to https://www.cms.gov/Plan-Payment/
For State-by-State information on utilization of free preventive services and the Annual Wellness Visit, go to http://www.cms.gov/NewMedia/02_preventive.asp
For more information on Medicare’s prevention benefits, go to the Share the News. Share the Health! website: http://www.medicare.gov/share-the-health/or contact 1-800-MEDICARE.
At Medicare is Simple, we look to educate and enable you to choose among Medicare plans to help find the policy that may best fit your needs. Get free quotes using our advanced quoting technology. HealthCare Reform is also a hot topic of interest to people of all ages, and we look to keep you updated on the issues relevant to learning more. Medicare Is Simple 800-442-4915
Wednesday, December 7, 2011
Monday, December 5, 2011
Notice of Receivership of Quality Health Plans, Inc.
On November 16, 2011, Quality Health Plans, Inc. ("Quality") was ordered into receivership for purposes of rehabilitation by the Second Judicial Circuit Court in Leon County, Florida. The Florida Department of Financial Services is the court appointed Receiver of Quality. Without further court action, Quality has been ordered liquidated effective December 1, 2011.
Quality is a provider-sponsored health maintenance organization that obtained its Florida license in 2002 and began operations in January 2003. Headquartered in Tampa, Florida, Quality is a Medicare only HMO of approximately 10,000 Medicare subscribers. Medicare premiums and contracts are administered through a federal agency, the Centers for Medicare and Medicaid Services ("CMS"). Quality was previously ordered into a limited form of receivership on October 17, 2011.
Quality members' health care coverage continues uninterrupted during the period of rehabilitation. However, Quality's health care contracts will terminate upon the effective date of liquidation on December 1, 2011 and Quality will no longer provide health care coverage to the Quality members.
As of December 1, 2011, former Quality members will receive continued health care coverage as arranged by CMS. The Receiver and CMS are closely coordinating on these matters now and will have additional details available soon on the Receiver's website at www.myfloridacfo.com/receiver. The Receiver will also send a notice to the Quality members to notify them of the liquidation and receivership process. Quality members are urged to carefully read any letters they receive from the Receiver and/or CMS as they will include very important information about the member's health care coverage from December 1, 2011.
Consumer/Claim Calls:
Consumers with questions regarding Quality should visit the company's website at www.qualityhealthplans.com/ or call Quality directly at the numbers provided below.
Quality Health Plan – Direct Contact Information:
Customer Services:1-866-747-2700
Utilization Management (for referrals, pre-certification or case management): 1-866-747-2300
Provider Relations & Network Services: 1-727-945-8400 x 8515
Main office number: (813) 574-1640
Mailing Address: 4010 Gunn Highway, Suite 220, Tampa, Fl. 33618-8744
Website: www.qualityhealthplans.com
For any other questions, consumers are asked to contact the Receiver by using the "Contact Us" form at the Receiver's website, www.MyFloridaCFO.com/Receiver or call the Florida Department of Financial Services, as Receiver, at 1-800-882-3054 or (850) 413-3081. Copies of the relevant information and documents are available on the Receiver's website, www.MyFloridaCFO.com/Receiver.
Quality is a provider-sponsored health maintenance organization that obtained its Florida license in 2002 and began operations in January 2003. Headquartered in Tampa, Florida, Quality is a Medicare only HMO of approximately 10,000 Medicare subscribers. Medicare premiums and contracts are administered through a federal agency, the Centers for Medicare and Medicaid Services ("CMS"). Quality was previously ordered into a limited form of receivership on October 17, 2011.
Quality members' health care coverage continues uninterrupted during the period of rehabilitation. However, Quality's health care contracts will terminate upon the effective date of liquidation on December 1, 2011 and Quality will no longer provide health care coverage to the Quality members.
As of December 1, 2011, former Quality members will receive continued health care coverage as arranged by CMS. The Receiver and CMS are closely coordinating on these matters now and will have additional details available soon on the Receiver's website at www.myfloridacfo.com/receiver. The Receiver will also send a notice to the Quality members to notify them of the liquidation and receivership process. Quality members are urged to carefully read any letters they receive from the Receiver and/or CMS as they will include very important information about the member's health care coverage from December 1, 2011.
Consumer/Claim Calls:
Consumers with questions regarding Quality should visit the company's website at www.qualityhealthplans.com/ or call Quality directly at the numbers provided below.
Quality Health Plan – Direct Contact Information:
Customer Services:1-866-747-2700
Utilization Management (for referrals, pre-certification or case management): 1-866-747-2300
Provider Relations & Network Services: 1-727-945-8400 x 8515
Main office number: (813) 574-1640
Mailing Address: 4010 Gunn Highway, Suite 220, Tampa, Fl. 33618-8744
Website: www.qualityhealthplans.com
For any other questions, consumers are asked to contact the Receiver by using the "Contact Us" form at the Receiver's website, www.MyFloridaCFO.com/Receiver or call the Florida Department of Financial Services, as Receiver, at 1-800-882-3054 or (850) 413-3081. Copies of the relevant information and documents are available on the Receiver's website, www.MyFloridaCFO.com/Receiver.
Medicare Gives Employers, Consumers Information to Make Better Health Care 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
MEDICARE NEWS
FOR IMMEDIATE RELEASE Contact: CMS Media Relations Group
December 5, 2011 (202) 690-6145
Medicare Gives Employers, Consumers Information to Make Better Health Care Choices
Health care law will allow patients to compare options, find best value
Consumers and employers will have the health care information they need to make more informed choices about their care, thanks to the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) announced in a final rule today.
The rule gives qualified organizations, like employers and consumer groups, access to data that can help them identify high quality health care providers or create online tools to help consumers make educated health care choices. Information that could identify specific patients, however, will not be publicly released and strong penalties will be in place for any misuse of data.
“This is a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs,” said Marilyn Tavenner, Acting CMS Administrator. “This provision of the health care law will ensure consumers have the access they deserve to information that will help them receive the highest quality care at the best value for their dollar.”
For years, employers, consumers, and health care quality advocates have expressed frustration about the limited and piecemeal availability of Medicare data that could be used to help evaluate health care provider or supplier performance. Although many health plans have created provider and supplier performance reports, these reports are based solely on the health plans' own claims, and do not reflect information from other health plans, including Medicare.
Providers, too, have expressed frustration at receiving performance reports that are piecemeal and produced without an opportunity for review and correction. This final rule creates a framework for providers to receive a single, actionable performance report covering all or most of their practice.
The final rule makes a number of important changes from the original proposed rule. The final rule makes this data less costly for qualified entities, gives qualified organizations more flexibility in their use of Medicare data to create performance reports for consumers, and extends the time period for health care providers to confidentially review and appeal performance reports before they become public. The rule also includes strict privacy and security requirements to protect patients, health care providers, and suppliers as well as stringent penalties for any misuse of Medicare data.
For more information on the final rule, visit:
The final rule on Availability of Medicare Data for Performance Measurement is on display until Dec. 7, 2011 at the Office of the Federal Register at: http://www.ofr.gov/OFRUpload/OFRData/2011-31232_PI.pdf
# # #
FACT SHEET
FOR IMMEDIATE RELEASE Contact: CMS Media Relations Group
December 5, 2011 (202) 690-6145
Final rule on release of Medicare data to be used for performance measurement
On Dec. 5, 2011, the Centers for Medicare & Medicaid Services (CMS) announced a final rule that will make more information available to the public about the performance of providers and suppliers, while protecting patient privacy. The final rule explains how organizations can become qualified by CMS to receive standardized extracts of Medicare claims data under Parts A, B, and D for the purpose of measuring provider and supplier performance.
The final rule is required by the Affordable Care Act as part of an initiative to promote transparency in the provision of health care services, giving beneficiaries access to information that will help them make more informed decisions about their health care. CMS has made significant modifications in the final rule to respond to concerns expressed in comments about the cost and timeliness of data, flexibility and innovation in measure calculation, and timeframes for provider’s and supplier’s review and appeal of draft reports.
Provisions of the Final Rule
Eligibility Requirements
To be eligible to participate in the program, qualified entities and their contractors will need to have experience in a variety of tasks related to the calculation and reporting of performance measures, including combining claims data from different payers, designing performance reports, sharing performance reports with the public, working with providers and suppliers regarding requests for error correction, and ensuring the privacy and security of data. Qualified entities will also need to have access to claims data from other sources to combine with the Medicare data in the evaluation of providers and suppliers. They will also need strong systems to ensure the data is secure and protected.
In response to public comments, CMS made the following changes in the final rule:
• Clarified that qualified entities do not need to be a single organization. Applicants may contract with others to achieve the ability to meet the eligibility criteria. Specifically, entities can demonstrate expertise and experience through activities it has conducted directly or through (a) contract(s) with other public or private entities.
• Revised the selection criteria to allow applicants to apply and receive a conditional acceptance as a qualified entity if they do not have other claims data at the time of their application, but meet all the other selection requirements.
Standard and Alternative Measures and Public Reporting
In the NPRM, CMS proposed to allow qualified entities to use only measures calculated in full from claims data. Comments from potential qualified entities, providers, and consumer groups stated that measures that incorporate clinical data offer a more complete and accurate picture of the performance of providers and suppliers. In response to these comments, the final rule allows qualified entities to use standard and alternative measures calculated in full or in part from claims data. This means that qualified entities can calculate measures that include clinical data.
As proposed in the NPRM, standard measures would include any measures endorsed by the National Quality Forum; measures developed pursuant to section 931 of the Public Health Service Act; or claims-based measures that were adopted through rulemaking for use in a current CMS program that includes performance measurement. In the final rule, CMS added measures endorsed by a CMS-approved consensus-based entity to the list of standard measures. CMS will approve organizations as consensus-based entities based on review of documentation of the consensus-based entity’s measure approval process.
Individuals or organizations will also be able to submit alternative measures to the Secretary for approval. In the NPRM, CMS proposed that notice and comment rulemaking would be used to obtain public comment on a proposed alternative measure and to help the Secretary determine if the proposed measure is more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use than existing claims-based measures. The final rule retains the original proposal and establishes a second process by which qualified entities may seek approval to use alternative measures. The new provision allows a qualified entity to receive approval to use an alternative measure by submitting documentation to CMS outlining consultation and agreement with stakeholders in the geographic region the qualified entity serves and scientific evidence that the measure is “more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by such standard measures.” Stakeholders must include the input of a valid cross representation of providers of services, suppliers, employers, payers, and consumers in any such request.
The final rule also clarifies that these regulations do not place any added limitations on the qualified entity’s ability to copyright the content of the publicly released reports. However, the qualified entity must provide confidential reports to providers of services and suppliers discussed in the reports free of charge and must provide the final reports to the public in a manner consistent with the requirements in the statute.
Data Extraction and Dissemination
In response to public comments about the cost and timeliness of the Medicare claims data, CMS identified efficiencies that will reduce the cost of Medicare claims data under the qualified entity program. CMS estimated that the average cost for a qualified entity for the first year of the program is $40,000, down from the $200,000 estimate in the proposed rule. The estimate is based off the assumption that there will be 25 qualified entities and that the average qualified entity will request data for approximately 2.5 million beneficiaries. In addition, CMS changed the rule to give qualified entities access to more timely Medicare claims data.
In the NPRM, CMS proposed to only release nationwide Medicare claims data if a qualified entity had sufficient other claims data to match with the Medicare data. CMS received multiple comments requesting that CMS release nationwide Medicare claims data to allow qualified entities to calculate benchmarks for performance measures. In response to public comments, CMS will allow qualified entities to purchase a 5 percent national sample of Medicare claims data for the purpose of calculating national benchmarks.
Data Privacy and Security
Qualified entities will be required to implement strict security and privacy requirements during all phases of the performance measure calculation, confidential reporting to providers and suppliers, appeal, and public reporting processes. Qualified entities will be required to have experience establishing, maintaining, and monitoring a rigorous data privacy and security program, and to submit documentation of rigorous data privacy and security policies.
Before receiving Medicare data, qualified entities will be required to sign a Data Use Agreement (DUA) with CMS that requires them to submit documentation of any inappropriate disclosures or uses of individually identifiable data to CMS, and to inform each individual whose health information has been inappropriately accessed.
Confidential Opportunities to Review, Appeal, and Correct Errors
Prior to publication of any performance reports, qualified entities would be required to confidentially share measures, measurement methodologies, and measure results with providers and suppliers. The providers and suppliers being measured would be able to request the Medicare data used to calculate performance measures in order to analyze the draft reports and request the correction of errors where needed. The proposed rule required qualified entities to share measures, measurement methodology, and measure results with providers and suppliers at least 30 business days prior to making measurement results public. In response to public comments that the 30-day review period was too short, CMS has finalized a review period of at least 60 calendar days.
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
December 5, 2011 (202) 690-6145
Medicare Gives Employers, Consumers Information to Make Better Health Care Choices
Health care law will allow patients to compare options, find best value
Consumers and employers will have the health care information they need to make more informed choices about their care, thanks to the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) announced in a final rule today.
The rule gives qualified organizations, like employers and consumer groups, access to data that can help them identify high quality health care providers or create online tools to help consumers make educated health care choices. Information that could identify specific patients, however, will not be publicly released and strong penalties will be in place for any misuse of data.
“This is a giant step forward in making our health care system more transparent and promoting increased competition, accountability, quality and lower costs,” said Marilyn Tavenner, Acting CMS Administrator. “This provision of the health care law will ensure consumers have the access they deserve to information that will help them receive the highest quality care at the best value for their dollar.”
For years, employers, consumers, and health care quality advocates have expressed frustration about the limited and piecemeal availability of Medicare data that could be used to help evaluate health care provider or supplier performance. Although many health plans have created provider and supplier performance reports, these reports are based solely on the health plans' own claims, and do not reflect information from other health plans, including Medicare.
Providers, too, have expressed frustration at receiving performance reports that are piecemeal and produced without an opportunity for review and correction. This final rule creates a framework for providers to receive a single, actionable performance report covering all or most of their practice.
The final rule makes a number of important changes from the original proposed rule. The final rule makes this data less costly for qualified entities, gives qualified organizations more flexibility in their use of Medicare data to create performance reports for consumers, and extends the time period for health care providers to confidentially review and appeal performance reports before they become public. The rule also includes strict privacy and security requirements to protect patients, health care providers, and suppliers as well as stringent penalties for any misuse of Medicare data.
For more information on the final rule, visit:
The final rule on Availability of Medicare Data for Performance Measurement is on display until Dec. 7, 2011 at the Office of the Federal Register at: http://www.ofr.gov/OFRUpload/OFRData/2011-31232_PI.pdf
# # #
FACT SHEET
FOR IMMEDIATE RELEASE Contact: CMS Media Relations Group
December 5, 2011 (202) 690-6145
Final rule on release of Medicare data to be used for performance measurement
On Dec. 5, 2011, the Centers for Medicare & Medicaid Services (CMS) announced a final rule that will make more information available to the public about the performance of providers and suppliers, while protecting patient privacy. The final rule explains how organizations can become qualified by CMS to receive standardized extracts of Medicare claims data under Parts A, B, and D for the purpose of measuring provider and supplier performance.
The final rule is required by the Affordable Care Act as part of an initiative to promote transparency in the provision of health care services, giving beneficiaries access to information that will help them make more informed decisions about their health care. CMS has made significant modifications in the final rule to respond to concerns expressed in comments about the cost and timeliness of data, flexibility and innovation in measure calculation, and timeframes for provider’s and supplier’s review and appeal of draft reports.
Provisions of the Final Rule
Eligibility Requirements
To be eligible to participate in the program, qualified entities and their contractors will need to have experience in a variety of tasks related to the calculation and reporting of performance measures, including combining claims data from different payers, designing performance reports, sharing performance reports with the public, working with providers and suppliers regarding requests for error correction, and ensuring the privacy and security of data. Qualified entities will also need to have access to claims data from other sources to combine with the Medicare data in the evaluation of providers and suppliers. They will also need strong systems to ensure the data is secure and protected.
In response to public comments, CMS made the following changes in the final rule:
• Clarified that qualified entities do not need to be a single organization. Applicants may contract with others to achieve the ability to meet the eligibility criteria. Specifically, entities can demonstrate expertise and experience through activities it has conducted directly or through (a) contract(s) with other public or private entities.
• Revised the selection criteria to allow applicants to apply and receive a conditional acceptance as a qualified entity if they do not have other claims data at the time of their application, but meet all the other selection requirements.
Standard and Alternative Measures and Public Reporting
In the NPRM, CMS proposed to allow qualified entities to use only measures calculated in full from claims data. Comments from potential qualified entities, providers, and consumer groups stated that measures that incorporate clinical data offer a more complete and accurate picture of the performance of providers and suppliers. In response to these comments, the final rule allows qualified entities to use standard and alternative measures calculated in full or in part from claims data. This means that qualified entities can calculate measures that include clinical data.
As proposed in the NPRM, standard measures would include any measures endorsed by the National Quality Forum; measures developed pursuant to section 931 of the Public Health Service Act; or claims-based measures that were adopted through rulemaking for use in a current CMS program that includes performance measurement. In the final rule, CMS added measures endorsed by a CMS-approved consensus-based entity to the list of standard measures. CMS will approve organizations as consensus-based entities based on review of documentation of the consensus-based entity’s measure approval process.
Individuals or organizations will also be able to submit alternative measures to the Secretary for approval. In the NPRM, CMS proposed that notice and comment rulemaking would be used to obtain public comment on a proposed alternative measure and to help the Secretary determine if the proposed measure is more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use than existing claims-based measures. The final rule retains the original proposal and establishes a second process by which qualified entities may seek approval to use alternative measures. The new provision allows a qualified entity to receive approval to use an alternative measure by submitting documentation to CMS outlining consultation and agreement with stakeholders in the geographic region the qualified entity serves and scientific evidence that the measure is “more valid, reliable, responsive to consumer preferences, cost-effective, or relevant to dimensions of quality and resource use not addressed by such standard measures.” Stakeholders must include the input of a valid cross representation of providers of services, suppliers, employers, payers, and consumers in any such request.
The final rule also clarifies that these regulations do not place any added limitations on the qualified entity’s ability to copyright the content of the publicly released reports. However, the qualified entity must provide confidential reports to providers of services and suppliers discussed in the reports free of charge and must provide the final reports to the public in a manner consistent with the requirements in the statute.
Data Extraction and Dissemination
In response to public comments about the cost and timeliness of the Medicare claims data, CMS identified efficiencies that will reduce the cost of Medicare claims data under the qualified entity program. CMS estimated that the average cost for a qualified entity for the first year of the program is $40,000, down from the $200,000 estimate in the proposed rule. The estimate is based off the assumption that there will be 25 qualified entities and that the average qualified entity will request data for approximately 2.5 million beneficiaries. In addition, CMS changed the rule to give qualified entities access to more timely Medicare claims data.
In the NPRM, CMS proposed to only release nationwide Medicare claims data if a qualified entity had sufficient other claims data to match with the Medicare data. CMS received multiple comments requesting that CMS release nationwide Medicare claims data to allow qualified entities to calculate benchmarks for performance measures. In response to public comments, CMS will allow qualified entities to purchase a 5 percent national sample of Medicare claims data for the purpose of calculating national benchmarks.
Data Privacy and Security
Qualified entities will be required to implement strict security and privacy requirements during all phases of the performance measure calculation, confidential reporting to providers and suppliers, appeal, and public reporting processes. Qualified entities will be required to have experience establishing, maintaining, and monitoring a rigorous data privacy and security program, and to submit documentation of rigorous data privacy and security policies.
Before receiving Medicare data, qualified entities will be required to sign a Data Use Agreement (DUA) with CMS that requires them to submit documentation of any inappropriate disclosures or uses of individually identifiable data to CMS, and to inform each individual whose health information has been inappropriately accessed.
Confidential Opportunities to Review, Appeal, and Correct Errors
Prior to publication of any performance reports, qualified entities would be required to confidentially share measures, measurement methodologies, and measure results with providers and suppliers. The providers and suppliers being measured would be able to request the Medicare data used to calculate performance measures in order to analyze the draft reports and request the correction of errors where needed. The proposed rule required qualified entities to share measures, measurement methodology, and measure results with providers and suppliers at least 30 business days prior to making measurement results public. In response to public comments that the 30-day review period was too short, CMS has finalized a review period of at least 60 calendar days.
Friday, December 2, 2011
Center Attorney Toby Edelman Testifies at Senate Aging Hearing About Overuse of Antipsychotic Drugs in Nursing Facilities
On November 30, 2011, the Senate Special Committee on Aging held a hearing entitled "Overprescribed: The Human and Taxpayers' Costs of Antipsychotics in Nursing Homes." This hearing was held largely in response to a May 2011 report issued by the Health and Human Services' Office of Inspector General (OIG) that, based on a review of Medicare claims data for 6 months in 2007, concluded "[i]n total, 95 percent (nearly 1.4 million) of Medicare claims for atypical antipsychotic drugs were for elderly nursing home residents diagnosed with off-label conditions and/or the condition specified in … boxed warning[s]."[1]
Following testimony from OIG and CMS, CMA Senior Policy Attorney Toby Edelman testified as a witness on a panel of experts on long-term care issues. In her testimony, Ms. Edelman, among other things: noted that this problem is a long-standing one (this Committee issued a report on the misuse of drugs in nursing homes in 1975 and held a workshop on reducing the use of chemical restraints in nursing homes in 1991); pointed out that the federal Nursing Home Reform Law prohibits the antipsychotic drug practices that we see in too many nursing homes, although the law is not adequately enforced; highlighted some of the reasons antipsychotics are inappropriately prescribed and the high costs of these drugs; and outlined some solutions to this problem. Ms. Edelman's written testimony is available at http://www.medicareadvocacy.org/2011/12/toby-edelman-testifies-before-senate-special-committee-regarding-antipsychotics-in-nursing-homes/. Also see previous Alerts written on this subject.[2]
________________________________________
[1] Office of Inspector General, Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents, OEI-07-08-00150, pages 14-18 (April 2011), http://www.oig.hhs.gov/oei/reports/oei-07-08-00150.pdf. Also see previous CMA Alert discussing this OIG report: "Real Solutions to Save Medicare Dollars in Skilled Nursing Facilities" (June 30, 2011), available at: http://www.medicareadvocacy.org/2011/06/real-solutions-to-
save-medicare-dollars-in-skilled-nursing-facilities/
[2] "Reducing Antipsychotic Drug Use in Nursing Homes: Save Residents' Lives, Save Medicare Billions of Dollars" (March 17, 2011) available at:
http://www.medicareadvocacy.org/2011/03/reducing-antipsychotic-drug-
use-in-nursing-homes-save-residents-lives-save-medicare-billions-of-dollars/; "Off-Label Drug Use is Common and Hurts Nursing Home Residents" (March 25, 2010), available at:
http://www.medicareadvocacy.org/InfoByTopic/SkilledNursingFacility
/10_03.25.OffLabelDrugUse.htm.
Following testimony from OIG and CMS, CMA Senior Policy Attorney Toby Edelman testified as a witness on a panel of experts on long-term care issues. In her testimony, Ms. Edelman, among other things: noted that this problem is a long-standing one (this Committee issued a report on the misuse of drugs in nursing homes in 1975 and held a workshop on reducing the use of chemical restraints in nursing homes in 1991); pointed out that the federal Nursing Home Reform Law prohibits the antipsychotic drug practices that we see in too many nursing homes, although the law is not adequately enforced; highlighted some of the reasons antipsychotics are inappropriately prescribed and the high costs of these drugs; and outlined some solutions to this problem. Ms. Edelman's written testimony is available at http://www.medicareadvocacy.org/2011/12/toby-edelman-testifies-before-senate-special-committee-regarding-antipsychotics-in-nursing-homes/. Also see previous Alerts written on this subject.[2]
________________________________________
[1] Office of Inspector General, Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents, OEI-07-08-00150, pages 14-18 (April 2011), http://www.oig.hhs.gov/oei/reports/oei-07-08-00150.pdf. Also see previous CMA Alert discussing this OIG report: "Real Solutions to Save Medicare Dollars in Skilled Nursing Facilities" (June 30, 2011), available at: http://www.medicareadvocacy.org/2011/06/real-solutions-to-
save-medicare-dollars-in-skilled-nursing-facilities/
[2] "Reducing Antipsychotic Drug Use in Nursing Homes: Save Residents' Lives, Save Medicare Billions of Dollars" (March 17, 2011) available at:
http://www.medicareadvocacy.org/2011/03/reducing-antipsychotic-drug-
use-in-nursing-homes-save-residents-lives-save-medicare-billions-of-dollars/; "Off-Label Drug Use is Common and Hurts Nursing Home Residents" (March 25, 2010), available at:
http://www.medicareadvocacy.org/InfoByTopic/SkilledNursingFacility
/10_03.25.OffLabelDrugUse.htm.
Understanding MA Plan Bonus Payments in 2012
Since the inception of Medicare private health plans under the Medicare Advantage (MA) program, plans have received ratings of one to five stars based on their performance on a number of quality measurements. These measurements reflect both medical and consumer experiences, including the quality of customer service, member satisfaction and health outcomes. The Affordable Care Act (ACA) changed the way plans are paid by eliminating overpayments to plans (before health reform, coverage under an MA plan cost Medicare 9 percent more per beneficiary than under Original Medicare). In addition, the ACA created a quality bonus payment system whereby plans are rewarded financially if they receive four- or five-star ratings. Plans are required to use bonus payments to provide extra benefits, such as coverage for eyeglasses and other vision care. However, the Centers for Medicare & Medicaid Services (CMS) expanded the policy through its demonstration authority to allow plans that receive star ratings of 3 or 3.5 to also receive bonus payments. The goal of the bonus payment policy is to create incentives for MA plans to improve the quality of their services, and subsequently, their quality ratings.
The vast majority—91 percent—of MA plans will receive bonus payments based on quality star ratings this year, according to a November report issued by the Kaiser Family Foundation titled “Medicare Advantage Plan Star Ratings and Bonus Payments in 2012.”The study also found that plans with star ratings of 3 or 3.5 (identifying them as average performers) will receive two-thirds of these bonuses. The remaining one-third of bonuses will be given to plans that achieve a star rating of four or higher. On average, MA plans will receive an estimated $281 bonus per enrollee in 2012, but that amount varies based on a number of factors, including the plan’s service area.
Read the Kaiser Family Foundation’s report “Medicare Advantage Plan Star Ratings and Bonus Payments in 2012.”
http://e.medicarerights-email.org/l.jsp?d=1947.177366.1282.4vNolfy8.A
The vast majority—91 percent—of MA plans will receive bonus payments based on quality star ratings this year, according to a November report issued by the Kaiser Family Foundation titled “Medicare Advantage Plan Star Ratings and Bonus Payments in 2012.”The study also found that plans with star ratings of 3 or 3.5 (identifying them as average performers) will receive two-thirds of these bonuses. The remaining one-third of bonuses will be given to plans that achieve a star rating of four or higher. On average, MA plans will receive an estimated $281 bonus per enrollee in 2012, but that amount varies based on a number of factors, including the plan’s service area.
Read the Kaiser Family Foundation’s report “Medicare Advantage Plan Star Ratings and Bonus Payments in 2012.”
http://e.medicarerights-email.org/l.jsp?d=1947.177366.1282.4vNolfy8.A
No Supercommittee Agreement; What Comes Next?
Last week the Joint Select Committee on Deficit Reduction, also known as the supercommittee, announced that its members were unable to agree on a package that would reduce the deficit by at least $1.2 trillion. With Medicare and Medicaid at the center of the supercommittee’s discussions, both programs would likely have faced difficult cuts had an agreement been reached. Ultimately, a major hurdle to agreement appeared to be the supercommittee’s lack of consensus on what proportion of deficit reduction should come from revenues compared to cuts.
As a result, as required by the Budget Control Act of 2011, aseries of automatic cuts known as a “sequester” will take effect in 2013, with reductions split evenly between defense spending and discretionary programs. Medicaid and Social Security are completely protected from the automatic cuts. Medicare is mostly protected, though the Medicare provider payment rates will be subject to a 2 percent cut. Other programs that remain at risk are those authorized by the Older Americans Act that provide services, including transportation and food assistance, to older Americans. Some members of Congress are already decrying the cuts to defense spending, but reducing them would result in deeper cuts to discretionary programs that provide needed services to older Americans.
While many of the proposals under consideration by the supercommittee, including raising the Medicare eligibility age and increasing Medicare cost-sharing, have not been included in the sequester package, they and similar proposals will continue to receive attention from policymakers in future deficit reduction and entitlement reform discussions.
Learn more about the Budget Control Act of 2011 and what happens now.
www.medicareinteractive.org.
As a result, as required by the Budget Control Act of 2011, aseries of automatic cuts known as a “sequester” will take effect in 2013, with reductions split evenly between defense spending and discretionary programs. Medicaid and Social Security are completely protected from the automatic cuts. Medicare is mostly protected, though the Medicare provider payment rates will be subject to a 2 percent cut. Other programs that remain at risk are those authorized by the Older Americans Act that provide services, including transportation and food assistance, to older Americans. Some members of Congress are already decrying the cuts to defense spending, but reducing them would result in deeper cuts to discretionary programs that provide needed services to older Americans.
While many of the proposals under consideration by the supercommittee, including raising the Medicare eligibility age and increasing Medicare cost-sharing, have not been included in the sequester package, they and similar proposals will continue to receive attention from policymakers in future deficit reduction and entitlement reform discussions.
Learn more about the Budget Control Act of 2011 and what happens now.
www.medicareinteractive.org.
Thursday, December 1, 2011
Reform-Based Initiatives on Dual Eligibles Take Shape, Offering Big Potential for Plans
Reprinted from AIS's HEALTH REFORM WEEK, the nation’s leading publication on the business implications of the massive changes for the health industry mandated by reform.
By James Gutman, Managing Editor
November 21, 2011 Volume 2 Issue 36
Despite — and perhaps even because of — budget problems, a host of large-scale federal and state initiatives growing out of the reform law are taking shape to better manage the care and costs of Medicare-Medicaid dual eligibles (DEs). The results could include huge new opportunities for both Medicare Advantage (MA) and Medicaid plans.
Aiding the plans’ interest is the willingness of the new Federal Coordinated Health Care Office in CMS to allow approaches that involve “passive” enrollment of DEs into MA plans, as long as the beneficiaries assigned have the opportunity to opt out. While there is resistance to this concept from some patient-advocacy organizations, others seem willing to accept it if there are good patient protections and additional services provided.
Moreover, the CMS duals office’s initiatives are helping to spur efforts by numerous states, led by Michigan and California, to ready their own giant requests for proposals (RFPs) on programs to manage DEs. The insurers know there are 9.2 million DEs in the nation, their medical costs total about $310 billion annually, and less than 1 million of them now are in managed care plans.
But there also are problems looming for these reform-linked efforts, even aside from the difficulties of managing an extremely poor and sick population. Although there already is reform-law money being spent for the duals office’s initiatives, and its efforts have some bipartisan support, the money comes from the reform-law-created CMS Center for Medicare and Medicaid Innovation, and CMMI’s future increasingly is under attack from congressional Republicans (see story, p. 3).
Probably the biggest reason for plan optimism about the DE market relates to the quick start the less-than-year-old CMS duals office has had in developing large-scale demonstration projects that states have embraced. And one big reason for this embrace is that the initiatives, unlike some others proposed previously, let states share significantly in the savings Medicare stands to get. The “misalignment” issue is one familiar to Melanie Bella, the director of the CMS duals office and a former Indiana Medicaid director, she tells HRW in an interview. As a result, her office proposed in July Medicare-Medicaid financial alignment models that include states sharing in savings, and 37 states have submitted nonbinding letters of intent to participate.
This new thrust, slated for implementation in 2012, builds on one the duals office already has begun involving states getting $1 million grants to develop integrated care programs for DEs. The duals office, according to Bella, has “design contracts” with 15 states to furnish specified integrated services for DEs.
The office’s demonstration initiative pursues the integration goal by offering states two models to choose from. One is a capitated model in which a state, CMS and a health plan enter into a three-way contract, and the plan gets a “prospective blended payment to provide comprehensive coordinated care.” While CMS wants the program to save money versus what now is spent on duals, Bella notes, the blended rate, which is paid to the plans rather than directly to the states, figures to help states concerned about a hike in their short-term costs as they establish integrated care for DEs. The second option is a “managed fee-for-service” model, under which a state and CMS enter into an agreement that enables states to share in savings resulting from initiatives to improve quality.
Programs Will Need Long-Term Care Services
The duals office, though, is demanding in what it seeks — integration “across the full range of primary, acute, behavioral health and long term supports and services.” Bella notes that this means, among other things, long-term care services in both institutional and community settings plus home health care.
As a carrot to sweeten participation, the duals office intends to allow states to “passively” enroll DEs into plans as long as the beneficiaries have clear rights to opt out and if there is at least one other plan option available.
Asked about advocacy organizations’ view of this, Bella acknowledges that “historically” they have expressed “concern” about passive enrollment. Lately, however, she asserts, her office’s discussions with such groups have focused more on what beneficiary protections will be involved since the groups recognize states are cutting back benefits (e.g., dental care) in the face of their budget woes, and the integrated programs offer a way to provide more services.
The duals office’s program, she adds, is designed to allow and is generating interest from a wide variety of organizations, including MA Special Needs Plans (SNPs), Medicaid plans and provider entities.
She maintains that the ongoing congressional debates about CMMI’s funding should not affect the duals office’s initiatives under way, saying that the demonstration programs involved “don’t require a lot of external funding” and that there is bipartisan support for them.
Richard Bringewatt, co-chair of the SNP Alliance trade group, agrees, pointing to the support evident — including from Sen. Orrin Hatch (R-Utah) — when Bella testified about the initiatives before congressional committees. But Bringewatt does express concerns about other funding-related issues, including the potential to “rip out [federal] funding for infrastructure” that is needed for the DE programs.
Moreover, says Valerie Wilbur, the alliance’s other co-chair, states “at some point will have to step up to the table” to help on financing themselves. States now, she notes, are waiting to hear how much savings CMS expects the DE programs to produce, and that’s a figure Bella hasn’t offered yet. Bella did tell the Senate Finance Committee in September it will take time before savings are realized. Wilbur herself tells HRW much of the savings will come as a result of including long-term and behavioral care in the services available to the DEs.
The lack of savings figures, though, doesn’t seem to be deterring state efforts to move ahead on DE programs. Michigan is hoping to issue its RFP in the first quarter of 2012, and Wilbur says California wants to send out a “request for solutions” in January or February. The earliest such programs seemingly could be implemented, she says, is the beginning of 2013, with marketing beginning in fall 2012. Both states are among the 15 getting duals-office grants.
What business entities will be the big winners from the initiatives on DEs? Wilbur says Medicaid managed care plans will “show a lot of growth,” especially since they already are involved in care for DEs and since states are more familiar with that than with Medicare.
But states will have to realize, contends Bringewatt, that the keys to cost savings are on the Medicare side. “We’re putting our money on a partnership” of the Medicare and Medicaid programs, he tells HRW.
‘De-institutionalization’ of DEs Is Seen as Key
There may be plenty of business to go around, suggests consultant John Gorman, CEO of Gorman Health Group, LLC. Speaking at a session of the Medicaid Health Plans of America annual meeting in Washington, D.C., Nov. 8, he noted that the annual cost of duals is about twice as high as the amount MA plans are paid. Moreover, health plans are the key for the needed “de-institutionalization” of DEs.
To illustrate the size of the business opportunities, Gorman said that Michigan intends to put all 220,000 of its DEs in managed care plans by the end of 2012 via an RFP that will involve $8 billion in revenues. And California, according to Gorman, intends to have 150,000 DEs in managed care by the end of 2012 and the rest by 2015 via an RFP that he values at $21 billion. He forecast that those and other state and federal moves mean that CMS Administrator Donald Berwick, M.D.’s goal of 1 million DEs in managed care by the end of 2012 will be blown “out of the water.”
SNPs will be the main “vehicle” for managed care for DEs, and they already account for 81% of SNP enrollees, he pointed out. New DE SNPs will be starting in 2012, Gorman added, and Blue Cross Blue Shield plans are looking at Medicaid much more than in the past, largely with DEs in mind. “There will be a street fight like we haven’t seen at the state level,” he predicted.
By James Gutman, Managing Editor
November 21, 2011 Volume 2 Issue 36
Despite — and perhaps even because of — budget problems, a host of large-scale federal and state initiatives growing out of the reform law are taking shape to better manage the care and costs of Medicare-Medicaid dual eligibles (DEs). The results could include huge new opportunities for both Medicare Advantage (MA) and Medicaid plans.
Aiding the plans’ interest is the willingness of the new Federal Coordinated Health Care Office in CMS to allow approaches that involve “passive” enrollment of DEs into MA plans, as long as the beneficiaries assigned have the opportunity to opt out. While there is resistance to this concept from some patient-advocacy organizations, others seem willing to accept it if there are good patient protections and additional services provided.
Moreover, the CMS duals office’s initiatives are helping to spur efforts by numerous states, led by Michigan and California, to ready their own giant requests for proposals (RFPs) on programs to manage DEs. The insurers know there are 9.2 million DEs in the nation, their medical costs total about $310 billion annually, and less than 1 million of them now are in managed care plans.
But there also are problems looming for these reform-linked efforts, even aside from the difficulties of managing an extremely poor and sick population. Although there already is reform-law money being spent for the duals office’s initiatives, and its efforts have some bipartisan support, the money comes from the reform-law-created CMS Center for Medicare and Medicaid Innovation, and CMMI’s future increasingly is under attack from congressional Republicans (see story, p. 3).
Probably the biggest reason for plan optimism about the DE market relates to the quick start the less-than-year-old CMS duals office has had in developing large-scale demonstration projects that states have embraced. And one big reason for this embrace is that the initiatives, unlike some others proposed previously, let states share significantly in the savings Medicare stands to get. The “misalignment” issue is one familiar to Melanie Bella, the director of the CMS duals office and a former Indiana Medicaid director, she tells HRW in an interview. As a result, her office proposed in July Medicare-Medicaid financial alignment models that include states sharing in savings, and 37 states have submitted nonbinding letters of intent to participate.
This new thrust, slated for implementation in 2012, builds on one the duals office already has begun involving states getting $1 million grants to develop integrated care programs for DEs. The duals office, according to Bella, has “design contracts” with 15 states to furnish specified integrated services for DEs.
The office’s demonstration initiative pursues the integration goal by offering states two models to choose from. One is a capitated model in which a state, CMS and a health plan enter into a three-way contract, and the plan gets a “prospective blended payment to provide comprehensive coordinated care.” While CMS wants the program to save money versus what now is spent on duals, Bella notes, the blended rate, which is paid to the plans rather than directly to the states, figures to help states concerned about a hike in their short-term costs as they establish integrated care for DEs. The second option is a “managed fee-for-service” model, under which a state and CMS enter into an agreement that enables states to share in savings resulting from initiatives to improve quality.
Programs Will Need Long-Term Care Services
The duals office, though, is demanding in what it seeks — integration “across the full range of primary, acute, behavioral health and long term supports and services.” Bella notes that this means, among other things, long-term care services in both institutional and community settings plus home health care.
As a carrot to sweeten participation, the duals office intends to allow states to “passively” enroll DEs into plans as long as the beneficiaries have clear rights to opt out and if there is at least one other plan option available.
Asked about advocacy organizations’ view of this, Bella acknowledges that “historically” they have expressed “concern” about passive enrollment. Lately, however, she asserts, her office’s discussions with such groups have focused more on what beneficiary protections will be involved since the groups recognize states are cutting back benefits (e.g., dental care) in the face of their budget woes, and the integrated programs offer a way to provide more services.
The duals office’s program, she adds, is designed to allow and is generating interest from a wide variety of organizations, including MA Special Needs Plans (SNPs), Medicaid plans and provider entities.
She maintains that the ongoing congressional debates about CMMI’s funding should not affect the duals office’s initiatives under way, saying that the demonstration programs involved “don’t require a lot of external funding” and that there is bipartisan support for them.
Richard Bringewatt, co-chair of the SNP Alliance trade group, agrees, pointing to the support evident — including from Sen. Orrin Hatch (R-Utah) — when Bella testified about the initiatives before congressional committees. But Bringewatt does express concerns about other funding-related issues, including the potential to “rip out [federal] funding for infrastructure” that is needed for the DE programs.
Moreover, says Valerie Wilbur, the alliance’s other co-chair, states “at some point will have to step up to the table” to help on financing themselves. States now, she notes, are waiting to hear how much savings CMS expects the DE programs to produce, and that’s a figure Bella hasn’t offered yet. Bella did tell the Senate Finance Committee in September it will take time before savings are realized. Wilbur herself tells HRW much of the savings will come as a result of including long-term and behavioral care in the services available to the DEs.
The lack of savings figures, though, doesn’t seem to be deterring state efforts to move ahead on DE programs. Michigan is hoping to issue its RFP in the first quarter of 2012, and Wilbur says California wants to send out a “request for solutions” in January or February. The earliest such programs seemingly could be implemented, she says, is the beginning of 2013, with marketing beginning in fall 2012. Both states are among the 15 getting duals-office grants.
What business entities will be the big winners from the initiatives on DEs? Wilbur says Medicaid managed care plans will “show a lot of growth,” especially since they already are involved in care for DEs and since states are more familiar with that than with Medicare.
But states will have to realize, contends Bringewatt, that the keys to cost savings are on the Medicare side. “We’re putting our money on a partnership” of the Medicare and Medicaid programs, he tells HRW.
‘De-institutionalization’ of DEs Is Seen as Key
There may be plenty of business to go around, suggests consultant John Gorman, CEO of Gorman Health Group, LLC. Speaking at a session of the Medicaid Health Plans of America annual meeting in Washington, D.C., Nov. 8, he noted that the annual cost of duals is about twice as high as the amount MA plans are paid. Moreover, health plans are the key for the needed “de-institutionalization” of DEs.
To illustrate the size of the business opportunities, Gorman said that Michigan intends to put all 220,000 of its DEs in managed care plans by the end of 2012 via an RFP that will involve $8 billion in revenues. And California, according to Gorman, intends to have 150,000 DEs in managed care by the end of 2012 and the rest by 2015 via an RFP that he values at $21 billion. He forecast that those and other state and federal moves mean that CMS Administrator Donald Berwick, M.D.’s goal of 1 million DEs in managed care by the end of 2012 will be blown “out of the water.”
SNPs will be the main “vehicle” for managed care for DEs, and they already account for 81% of SNP enrollees, he pointed out. New DE SNPs will be starting in 2012, Gorman added, and Blue Cross Blue Shield plans are looking at Medicaid much more than in the past, largely with DEs in mind. “There will be a street fight like we haven’t seen at the state level,” he predicted.
Subscribe to:
Posts (Atom)