Compliance officers “are not the guarantor of compliance. This is one trap most compliance officers fall into. We try to do compliance on behalf of the company and we feel guilty when things go wrong and we have no control. [But] compliance is everyone’s job. Don’t beg people, ‘would you do this for me?’ The strategic tactic is to give everyone a job. Let them help you paint the fence.”
— Steve Grubb, global compliance and ethics director for Diageo, told a recent HCCA webinar on fighting stress, as reported in AIS’s Report on Medicare Compliance.
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Tuesday, June 12, 2012
Friday, June 8, 2012
Increase in Observation Stays May Cause Problems for Medicare Beneficiaries
The ratio of observation stays to inpatient admissions in Original Medicare increased 34 percent from 2007 to 2009, according to a study published in Health Affairs this week. Additionally, Medicare beneficiaries were held in observation for longer periods of time—some for at least 72 hours, well past Medicare’s recommended 24 to 48 hours. Observation services allow physicians to evaluate a hospital patient when it is unclear whether or not that patient should be formally admitted. According to the article, the extended use of observation versus inpatient services can limit beneficiaries’ access to skilled nursing care and subject them to higher out-of-pocket costs.
The study, which utilizes Medicare claims data for beneficiaries over the age of 65, found that between 2007 and 2009, the number of beneficiaries held under observation status increased 24 percent. In addition, the number of beneficiaries held for observation stays for longer than 72 hours more than doubled. The study also finds that observation stays were more prevalent among certain population groups, including older Medicare beneficiaries and women.
According to the study, nearly one million Medicare beneficiaries aged 65 and older received observation services each year from 2007 to 2009, and each additional episode resulted in a longer observation stay. The study’s authors suggest that this trend may be a result of recent Medicare payment policies intended to reduce avoidable hospital readmissions and contain costs. The study suggests that this shift from inpatient admissions to observation stays may create barriers to skilled nursing facility care for those who need it, as Medicare requires that beneficiaries spend three days in an inpatient setting to qualify for skilled nursing care under the Part A benefit. Patients under observation status are considered outpatients.
http://www.medicare.gov/publications/pubs/pdf/11435.pdf
The study, which utilizes Medicare claims data for beneficiaries over the age of 65, found that between 2007 and 2009, the number of beneficiaries held under observation status increased 24 percent. In addition, the number of beneficiaries held for observation stays for longer than 72 hours more than doubled. The study also finds that observation stays were more prevalent among certain population groups, including older Medicare beneficiaries and women.
According to the study, nearly one million Medicare beneficiaries aged 65 and older received observation services each year from 2007 to 2009, and each additional episode resulted in a longer observation stay. The study’s authors suggest that this trend may be a result of recent Medicare payment policies intended to reduce avoidable hospital readmissions and contain costs. The study suggests that this shift from inpatient admissions to observation stays may create barriers to skilled nursing facility care for those who need it, as Medicare requires that beneficiaries spend three days in an inpatient setting to qualify for skilled nursing care under the Part A benefit. Patients under observation status are considered outpatients.
http://www.medicare.gov/publications/pubs/pdf/11435.pdf
New Report Underscores the Importance of Having Coverage for Accessing Needed Health Care
A new report released by the Kaiser Family Foundation (KFF), titled “Cost and Access Challenges: A Comparison of Experiences Between Uninsured and Privately Insured Adults Aged 55 to 64 with Seniors on Medicare,” finds that unsurprisingly, uninsured adults face significant difficulties accessing and affording needed health care. The report compares survey data on health care cost and access experiences of adults aged 55 to 64—with and without private insurance—and seniors with Medicare.
According to the report, over 41 percent of uninsured adults aged 55 to 64 postponed needed care in 2010, and almost all of these individuals attributed the reason to cost concerns. Compared to this population, a lower proportion of insured adults in the same age range and seniors with Medicare reported access and affordability issues. For instance, the uninsured adults surveyed had unmet medical needs or delayed seeking health care at three times the rate that Medicare seniors did. The report also finds that between 2003 and 2010, a higher proportion of both uninsured and insured adults surveyed have found it difficult to access care. In contrast, the share of Medicare seniors who experienced these accessibility problems did not change significantly.
According to the report, certain Medicare benefits protect older beneficiaries from experiencing difficulty accessing or affording care. For instance, a larger share of seniors without supplemental coverage reported having trouble paying their medical bills, compared to those with secondary insurance, such as employer-sponsored coverage, a Medigap, or Medicaid.
Thanks to the Affordable Care Act (ACA), beginning in 2014, uninsured adults will be able to purchase affordable insurance from state health exchanges. In the meantime, the law has mandated that states establish pre-existing condition plans for uninsured individuals; to date, adults aged 55 to 64 have been the largest enrollment group in those policies. Moreover, in 2014, those with limited incomes may become eligible for Medicaid due to expansion of this program or receive subsidies to purchase private insurance through the state exchanges. The KFF report cautions that limiting the implementation of the ACA or reducing Medicare benefits, such as by increasing the age of Medicare eligibility, could have serious cost and access implications for older Americans.
http://www.kff.org/medicare/8320.cfm
According to the report, over 41 percent of uninsured adults aged 55 to 64 postponed needed care in 2010, and almost all of these individuals attributed the reason to cost concerns. Compared to this population, a lower proportion of insured adults in the same age range and seniors with Medicare reported access and affordability issues. For instance, the uninsured adults surveyed had unmet medical needs or delayed seeking health care at three times the rate that Medicare seniors did. The report also finds that between 2003 and 2010, a higher proportion of both uninsured and insured adults surveyed have found it difficult to access care. In contrast, the share of Medicare seniors who experienced these accessibility problems did not change significantly.
According to the report, certain Medicare benefits protect older beneficiaries from experiencing difficulty accessing or affording care. For instance, a larger share of seniors without supplemental coverage reported having trouble paying their medical bills, compared to those with secondary insurance, such as employer-sponsored coverage, a Medigap, or Medicaid.
Thanks to the Affordable Care Act (ACA), beginning in 2014, uninsured adults will be able to purchase affordable insurance from state health exchanges. In the meantime, the law has mandated that states establish pre-existing condition plans for uninsured individuals; to date, adults aged 55 to 64 have been the largest enrollment group in those policies. Moreover, in 2014, those with limited incomes may become eligible for Medicaid due to expansion of this program or receive subsidies to purchase private insurance through the state exchanges. The KFF report cautions that limiting the implementation of the ACA or reducing Medicare benefits, such as by increasing the age of Medicare eligibility, could have serious cost and access implications for older Americans.
http://www.kff.org/medicare/8320.cfm
Tuesday, June 5, 2012
CMS ANNOUNCES DATA AND INFORMATION INITIATIVE
The Centers for Medicare & Medicaid Services (CMS) today announced a new data and information initiative that will be a key tool in the agency’s evolution from a fee-for-service based payer to a value-based purchaser of care.
The data and information initiative will be administered through a new Office of Information Products and Data Analytics (OIPDA) that will oversee CMS’s comprehensive portfolio of data and information. Under OIPDA, the development, management, use, and dissemination of data and information resources will become one of CMS’s core functions. Ensuring the privacy and security of personal health information remains a top priority as OIPDA improves access to, and use of, CMS data and information resources. With timely, relevant data, CMS and its partners will be better able to define and reward high quality, low cost care.
This effort also enhances data analytics and management strategies that are being widely promoted through programs by the White House Office of Science and Technology Policy.
Background
CMS provides healthcare coverage for more than 100 million Americans through Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Under Medicare alone, CMS processes more than 1.3 billion claims a year, and generates billions of other non-claim data points, such as eligibility checks, 1-800 MEDICARE queries, quality metrics and enrollment information. Additionally, CMS is receiving data submissions under the meaningful use requirements of the Medicare and Medicaid Electronic Health Records Incentive Programs and beginning to collect Medicare Advantage encounter data. Similarly, beginning in 2014, CMS will receive health insurance exchange data related to the coverage expansions under the Affordable Care Act.
This wealth of data is critical to decision making for CMS and other stakeholders in the nation’s health care system. CMS must leverage this data to inform internal decisions and has a public responsibility to provide appropriate access to data (while ensuring beneficiary privacy) to external stakeholders in order to facilitate healthcare innovation. At the same time, CMS recognizes the critical role of analytics in transforming data resources into information and insight. Through the creation of OIPDA, CMS is focusing resources to improve data access and dissemination, and enabling the development of new products and analysis tools designed to harness its data resources to better highlight relevant and actionable information for internal and external policy and decision makers. In all of these activities, CMS will ensure that all data release and dissemination processes follow privacy laws and regulations and that the release of beneficiary identifiable data is limited to cases permitted by statute and regulations. OIPDA will also focus on creating new and innovative mechanisms, such as virtual data centers that allow data users remote and secure access to the data, to improve appropriate access to beneficiary identifiable data for research and analysis, while simultaneously increasing data security.
Functions of the Office of Information Products and Data Analysis
The data and information initiative will be administered through a new Office of Information Products and Data Analytics (OIPDA) that will oversee CMS’s comprehensive portfolio of data and information. Under OIPDA, the development, management, use, and dissemination of data and information resources will become one of CMS’s core functions. Ensuring the privacy and security of personal health information remains a top priority as OIPDA improves access to, and use of, CMS data and information resources. With timely, relevant data, CMS and its partners will be better able to define and reward high quality, low cost care.
This effort also enhances data analytics and management strategies that are being widely promoted through programs by the White House Office of Science and Technology Policy.
Background
CMS provides healthcare coverage for more than 100 million Americans through Medicare, Medicaid, and the Children's Health Insurance Program (CHIP). Under Medicare alone, CMS processes more than 1.3 billion claims a year, and generates billions of other non-claim data points, such as eligibility checks, 1-800 MEDICARE queries, quality metrics and enrollment information. Additionally, CMS is receiving data submissions under the meaningful use requirements of the Medicare and Medicaid Electronic Health Records Incentive Programs and beginning to collect Medicare Advantage encounter data. Similarly, beginning in 2014, CMS will receive health insurance exchange data related to the coverage expansions under the Affordable Care Act.
This wealth of data is critical to decision making for CMS and other stakeholders in the nation’s health care system. CMS must leverage this data to inform internal decisions and has a public responsibility to provide appropriate access to data (while ensuring beneficiary privacy) to external stakeholders in order to facilitate healthcare innovation. At the same time, CMS recognizes the critical role of analytics in transforming data resources into information and insight. Through the creation of OIPDA, CMS is focusing resources to improve data access and dissemination, and enabling the development of new products and analysis tools designed to harness its data resources to better highlight relevant and actionable information for internal and external policy and decision makers. In all of these activities, CMS will ensure that all data release and dissemination processes follow privacy laws and regulations and that the release of beneficiary identifiable data is limited to cases permitted by statute and regulations. OIPDA will also focus on creating new and innovative mechanisms, such as virtual data centers that allow data users remote and secure access to the data, to improve appropriate access to beneficiary identifiable data for research and analysis, while simultaneously increasing data security.
Functions of the Office of Information Products and Data Analysis
OIPDA will assume responsibility for many current CMS data functions, including:
· Management of the Chronic Condition Warehouse (CCW), which is designed to support multiple analytic functions and includes patient-centric data files linked by a unique beneficiary identifier across the continuum of care from 1999 to present day. The CCW also contains Medicaid data, assessment data, and provider enrollment data.
· Administration and production of the Medicare Current Beneficiary Survey (MCBS), which is the largest continuous survey of Medicare beneficiaries in the country. The MCBS provides stable estimates and information on the Medicare population, such as expenditures and sources of payment for services used by beneficiaries, changes in health status, satisfaction with care, and usual source of care.
· Management of the Medicaid Analytic Extract (MAX), which is designed to summarize Medicaid data from the Medicaid Statistical Information System (MSIS).
· Oversight of the Research Data Assistance Center
· Oversight of the Medicare Data Sharing for Performance Measurement Program (ACA Section 10332), which provides extracts of all Medicare claims data to qualified entities who then combine the Medicare data with claims data from other payers to create comprehensive, actionable quality assessments for health care providers.
· Publication of aggregated Medicare demographic, spending, utilization, and quality information at the Hospital Referral Region (HRR) level.
· Oversight of the Medicare “Blue Button” initiative that permits beneficiaries to easily download their Medicare claims history.
OIPDA will also coordinate the agency’s data policies and requirements to ensure their efficient and strategic alignment. Other CMS components will continue to collect, store, and analyze data for their specific business needs, with OIPDA being responsible for ensuring that the CMS enterprise maximizes its data resources, transforming the agency into a data driven organization.
New OIPDA Data and Information Products
As first steps under the new data and information initiative, CMS is announcing the release of several new data and information products:
· Medicare Geographic Variation Trend Data:CMS is announcing a unique data set that leverages almost 5 billion Medicare claims over a four-year period into an easy-to-use data resource at the state and HRR levels. The data set includes numerous variables, such as demographics, spending, utilization and quality of care, across four years (2007-2010). This data set permits a variety of users with varying levels of experience with Medicare data to quickly understand and adapt the data to specific projects, and provides the ability to assess and compare their state’s or HRR’s Medicare performance against that of other areas or the national average. The data is on the Institute of Medicine website and will be available in the Health Indicators Warehouse by mid-summer 2012. View: http://www.iom.edu/Activities/HealthServices/GeographicVariation/Data-Resources.aspx and http://healthindicators.gov/Indicators/.
· Medicare Enrollment Dashboard: CMS is announcing an online dashboard that provides comprehensive statistics on Medicare enrollment (Parts A, B, and D and Medicare Advantage), including detailed information on enrollment patterns at both the national and state level for recent years, as well as historical trend data on overall Medicare enrollment beginning in 1966. This replaces a process where interested parties had to obtain information about Medicare Parts A, B, D and Medicare Advantage enrollment from multiple locations on the CMS website. Visit: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/View-Dashboards-Items/Medicare-Enrollment-Dashboard-BETA.html.
· Medicare & Medicaid Research Review (MMRR): CMS recently launched a new peer-reviewed online journal to support dissemination of high-quality and relevant research to a wide audience of Medicare, Medicaid, and Children's Health Insurance Program stakeholders. MMRR is currently accepting manuscripts that report on issues involving health care coverage, quality and access to care for beneficiaries, and payment for health services. MMRR will also publish CMS Data Briefs, summarizing complex statistical topics in easily understandable language designed to inform a more diverse community of health analysts and policymakers. Visit: www.cms.gov/Research-Statistics-Data-and-Systems/Research/MMRR/index.html.
· CMS Data Navigator: This web-based search tool rapidly connects researchers, policy makers, and the general public to the CMS data resources they need. Additionally, Navigator results will also link to CMS data housed on external web sites such as the Kaiser Family Foundation, the Institute of Medicine
More information on CMS’s initiative is available at http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ResearchGenInfo/OIPDA.html.
A press release on today’s announcement can be found at http://www.hhs.gov/news/.
HHS harnesses the power of health data to improve health
The Department of Health and Human Services (HHS), along with the Institute of Medicine (IoM) and other members of the Health Data Consortium, are co-hosting the third annual “Datapalooza” focusing on innovative applications and services that harness the power of open data from HHS and other sources to help improve health and health care.
The Health Data Initiative Forum III is featuring more than 100 new or updated solutions, up from 45 solutions last year, that help serve the needs of consumers, health care providers, employers, public health leaders, and policy makers.
“The innovators present today are a great example of how data and technology can be used in powerful ways to help consumers and providers improve health,” said HHS Secretary Kathleen Sebelius. “We’re not just creating new technology, but we’re empowering Americans to make better decisions about health and health care by putting information at their fingertips.”
Other announcements made at the Forum today include:
Data found in the Healthcare.gov Insurance Options Finder is now available through an application programming interface (API), enabling the data to be machine readable and downloaded by third party developers. The Insurance Options Finder allows users to compare different plans, showing important information, such as the percentage of people who applied for coverage and were denied. HealthCare.gov collects and displays public options, private insurance plans for individuals and families as well as the small group markets.
The Centers for Medicare & Medicaid Services (CMS) launched an initiative to transform the agency’s approach to data and analytics. The initiative will help guide the agency’s evolution from a fee-for-service based payer to a “value-based purchaser of care” that links payments to quality and efficiency of care, rather than sheer volume of services. To lead the initiative, CMS created a new Office of Information Products and Data Analysis, which will strive to make development, management, use, and dissemination of data and information resources a core function of CMS. This effort also enhances data analytics and management strategies that are being widely promoted through programs by the White House Office of Science and Technology Policy. The announcement builds upon many of the recent advances in data transparency and accessibility achieved by CMS in the past 12 months.
Over time, the initiative will modernize CMS’ intricate data systems and policies, and help the agency to achieve the greatest improvements in health care delivery. Data and information resources available under CMS’ initiative include:
- Medicare Geographic Variation Trend Data: A unique data set that leverages nearly 5 billion Medicare claims in an easy-to-use data format that provides key metrics at the state and hospital referral region levels.
- Medicare Enrollment Dashboard: An online dashboard that provides a single location with comprehensive statistics on Medicare enrollment (Parts A, B, and D and Medicare Advantage).
- Medicare & Medicaid Research Review: A peer-reviewed online journal on current and future directions of the Medicare, Medicaid and Children’s Health Insurance.
- CMS Data Navigator: A web-based search tool that rapidly connects researchers, policy makers, and the general public to the CMS data resources they need.
The Office for the National Coordinator for Health IT has led national competitions toward the creation of easy-to-use, web-based tools that help patients schedule follow-up appointments after being discharged from a hospital stay. In collaboration with the Partnership for Patients, the “Discharge Follow-Up Appointment Challenge” winners were announced:
- First place: MyHealthDIRECT, a web-based solution that enables patients and caregivers to search for, book, and confirm appointments and includes reminder and transportation reservation functionality.
- Second place: HePak, a tool that integrates appointment-making and reminder functions into its hospital, provider, and patient portals.
- Third place: mHealthCoach, a tool that provides calendar syncing and incorporates educational content and HHS data feeds.
Going From Difficult to Almost Impossible: Preparing Bids for 2013
By James Gutman - June 1, 2012
As Medicare Advantage and stand-alone Prescription Drug Plan sponsors head into the weekend before the Monday due date for their bids to CMS for 2013, they face far more major uncertainties than they did a year ago. It's enough to make an actuary want to tear his hair out — if he could find the time to do that.
Let's review just some of the unknowns that could have a major impact on product, service area, price and benefit decisions that need to be reflected in the bids. First, there are the 2% payment cuts plans stand to experience if the "sequestration" resulting from congressional failure to agree on budget cuts goes into effect in 2013. But Congress still could block those cuts in a "lame duck" session after the November elections. CMS has not provided any guidance on how plans should reflect this in bids, pointing out that there are statutory limits on what it can do. Then there are the huge new Medicare-Medicaid dual-eligible demonstration plans that could draw away enrollees from PDPs starting in 2013 — if the Supreme Court does not overthrow the whole health reform law on which those demos are based. Again, plans won't have any more info on this by the June 4 bid due date.
Next we have had delays, which are understandable given everything on CMS's plate, in getting plans data on such bid-affecting factors as low-income subsidy beneficiaries. And CMS on May 24 reissued the tool plans need to use in calculating out-of-pocket costs (OOPC) for beneficiaries because the tool, which is used to assess whether plans would be charging beneficiaries too much, wasn't calculating deductibles correctly. Moreover, plans will have to decide which areas they wish to serve for 2013 more than three months before they get their 2013 star ratings that can help determine whether certain service areas and products are even feasible next year.
How do you make these decisions with all of those uncertainties — not to mention the perennial one regarding what Congress will do on the big physician fee cuts slated to occur Jan. 1? Do you rely on the sage doctrine of John Maynard Keynes, who said that "in the long run, we're all dead," and just go ahead and plan for the short run, assuming nothing dramatic will change? Is ignorance bliss here? Have a good weekend!
Today's Datapoint
49,000 … was the Medicare Advantage enrollment increase for the May 1 payment date from the month-ago level, with Humana the biggest gainer at 67,000, according to data released by CMS.
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