Improving the Quality of Care for Medicare Beneficiaries by Increasing Patient Engagement

CMS BLOG http://blog.cms.gov/2016/12/08/improving-the-quality-of-care-for-medicare-beneficiaries-by-increasing-patient-engagement December 8, 2016 By: Patrick Conway, M.D., Principal Deputy Administrator and Chief Medical Officer, CMS and Andy B. Bindman, M.D. Director, Agency for Healthcare Research and Quality   Improving the Quality of Care for Medicare Beneficiaries by Increasing Patient Engagement  The Department of Health and Human Services (HHS) identifies the engagement of Medicare beneficiaries as a cornerstone to achieving better care, smarter spending, and healthier people. Our agencies – the Centers for Medicare & and Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) – support the vision set forth in CMS’ Quality Strategy, of health and care that is person-centered, provides incentives for the right outcomes, is sustainable, emphasizes coordinated care and shared decision making, and relies on transparency of quality and cost information. We know beneficiaries make health care decisions in a variety of ways. Often, these decisions involve multiple treatment options that can have different sets of advantages depending on the individual.  As such, beneficiaries may not always understand the health information that may be available online, in print or from their clinician and the options available to them.  They may not know what questions to ask clinicians, or feel that their values and preferences were considered and respected when a final decision for their treatment is reached. Engaging and empowering individuals to take ownership of their health involves giving people the tools they need to navigate the health care system – making health care information more accessible and helping to ensure that the patient’s voice is heard. With this in mind, CMS is announcing two new models from the CMS Innovation Center that will increase patient engagement in care decisions by putting more information in the hands of Medicare beneficiaries. These two Beneficiary Engagement and Incentives (BEI) Models are the Shared Decision Making Model (SDM Model) and the Direct Decision Support Model (DDS Model). Beneficiary engagement broadly refers to the actions and choices of individuals with regard to their health and health care, and these decisions impact cost, quality and patient satisfaction outcomes. The BEI models will test different approaches to shared decision making, acknowledging that beneficiaries make decisions regarding treatment options in a variety of ways, and that facilitating a better understanding of their health and health care decisions is key towards improved beneficiary engagement.  Shared Decision Making is a process of communication, deliberation, and decision making that includes sharing information with the beneficiary that outlines treatment options, including harms, benefits, and alternatives; eliciting and supporting the beneficiary’s values and preferences maintaining an interactive and meaningful dialogue based on the best medical evidence tailored to the beneficiary’s condition; and making an optimal decision that takes into account the evidence on options, practitioner/care team expertise, and the beneficiary’s values and preferences. The SDM Model will test the integration of a specific, structured Four Step process to shared decision making into routine clinical practice workflows of practitioners participating in Accountable Care Organizations (ACOs), resulting in informed and engaged beneficiaries who collaborate with their practitioners to make medical decisions that align with their values and preferences. The Model seeks to determine if this design results in improved beneficiary outcomes and lower Medicare spending while maintaining or improving quality, and whether it results in increased beneficiary satisfaction with care decisions. Beneficiaries who have one of the six preference-sensitive conditions will be offered an in-person collaborative process by their clinician that can help them understand and thoughtfully weigh their treatment options. These preference-sensitive conditions include: stable ischemic heart disease, hip or knee osteoarthritis, herniated disk or spinal stenosis, clinically localized prostate cancer (cancer that is confined to the prostate gland), and benign prostate hyperplasia. For example, information provided will help the beneficiary decide whether surgery or other medical treatments are the right choice for them. The SDM Model stipulates the use of decision aids and a structured Four Step process to be applied at all participating ACO practices, and expects to engage over 150,000 Medicare beneficiaries annually. The DDS Model will test an approach to shared decision making provided outside of the doctor’s office, by Decision Support Organizations that provide health management and decision support services.  For example, beneficiaries will be contacted by these organizations and provided access to a website or electronic application that provides them with unbiased and evidence-based information on their condition and/or treatment options. The beneficiary can then bring this information to their doctor’s office to enable them to consider their options with their clinician. This Model is designed to determine whether engaging beneficiaries outside the clinical care setting will enable them to become more informed, empowered and engaged health care consumers, and have a positive impact on their health care decision making. A major goal of the DDS Model is to encourage beneficiaries to have a greater role in their care by building and fostering the physician-patient relationship. It will use patient-friendly material to educate patients about their condition and encourage them to have a conversation with their practitioners about care options to determine what care is best for them. Providing information directly to patients about their health decisions acknowledges that patients make decisions about their medical conditions outside of, as well as inside, their doctor’s office. The model seeks to determine if this design results in reducing Medicare spending while maintaining or improving quality, and whether it results in increased beneficiary satisfaction with care decisions. The DDS Model uses organizations that are responsible for engaging an assigned population of Medicare fee-for-service beneficiaries in ongoing communications and medical decision support on behalf of CMS. These organizations may be commercial firms that already provide similar health information and decision support services to insured populations. Decision Support Organizations will not be health care providers or suppliers, will not engage in the practice of medicine, and will not interfere with the practitioner-patient relationship. They provide beneficiaries with reliable information that they can incorporate into discussions with their practitioners regarding health care decisions.   The Model expects to reach 700,000 Medicare fee-for-service beneficiaries annually. An independent evaluation will be conducted separately for the SDM and DDS models. The goal of the evaluation is to determine whether the particular model improves the quality of care without increasing spending; reduces spending without reducing quality of care; or improves quality of care and reduces spending. The evaluation will explore what aspects of the particular model contribute most to success and how contextual factors influence this success. These models will look to move beyond current practices and examine new ways to engage with patients with regard to their health and health care, and hopefully increase quality of care delivered, increase patient satisfaction, and provide value in the cost of care delivered. Both of these models incorporate lessons learned in previous CMS projects that included patient engagement and shared decision making components.  These innovations also build on ongoing activities at AHRQ, where creating evidence-based tools to support effective clinician-patient interaction is a priority. For instance, AHRQ’s SHARE Approach model is a five-step process for shared decision-making that includes exploring and comparing the benefits, harms, and risks of treatment options through meaningful dialogue about what matters most to the patient. The Effective Health Care Program, meanwhile, offers online decision aids and plain-language research summaries to help patients consider their treatment options for certain clinical conditions when meeting with clinicians.  Looking ahead, AHRQ is working to advance the field with new grant funding for projects up to $1.5 million to develop, test and evaluate measures of shared decision-making for research conducted in clinical settings. AHRQ also developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, which has been used as a model for a toolkit to ensure smooth ambulatory transitions in care. Together, new approaches such as CMS’ SDM and DDS models, along with evidence-based innovations like AHRQ’s SHARE approach and Guide to Patient and Family Engagement, will make better care, smarter spending, and healthier people a reality not only for Medicare beneficiaries, but patients and consumers everywhere.  Decision Support Organizations that are interested in participating in the DDS Model, and ACOs that are currently in the Medicare Shared Savings Program or Next Generation ACO Model and are interested in participating in the SDM Model must submit an electronic, non-binding Letter of Intent (LOI) for consideration for participation in the DDS and SDM Models, the first step of the application process. The LOI submission period begins on December 8, 2016 and closes on March 5, 2017. More information is available on the BEI Models website at: https://innovation.cms.gov/initiatives/Beneficiary-Engagement/ For more information on the DDS model, click here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-12-08.html  For more information on the SDM model, click here: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-12-08-2.html  ###  Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress

Remarks by Andy Slavitt: Keeping Medicare’s Promise with MACRA

Remarks by Andy Slavitt: Keeping Medicare’s Promise with MACRA

https://blog.cms.gov/2016/12/01/remarks-by-andy-slavitt-keeping-medicares-promise-with-macra/

 

 Below are prepared remarks by Andy Slavitt, CMS Acting Administrator before the MACRA MIPS/APM Summit, Washington, D.C. on December 1, 2016.

***

 

So, you decided to come to Washington to see what was new and how things might be changing… I am sure we did not disappoint. 

I am honored to have been invited to address this summit, which I’m sure will be your first of many. It's a certainty that making our delivery system work better for patients and spend money more wisely will always be in season no matter which party is in charge. And, while many new approaches and changes may come to bear, ultimately health is not a partisan issue. 

However, I do hope you all think of a better name– the MACRA MIPS/APM summit sounds like the world’s hardest word scramble. We’ve tried to make MACRA more accessible by naming it the Quality Payment Program… something to think about.  

Looking at your speakers today, you have gathered some of the most experienced people across the country focused on the most difficult health care problems we as a nation face. Simply put, how to complete the changes we have begun to make the system more patient centered and accountable. So today, I come here to add my perspective to this discussion and continue to ask for your valuable help. 

You, as clinical and business leaders, represent an active and important voice in the delivery of health care for all Americans. As we make changes, you are part of the leadership who will be the first to know what is working and what is not. You will also be the best at articulating what you need from Washington. At CMS, we have worked hard over the last few years to transform from an opaque bureaucracy into an accessible service organization, getting us closest to making decisions based on where care is provided across the country. 

I want to talk about the next evolution for our health care system. 

For nearly two years, I have had the incredible honor to serve at CMS and to oversee the Medicare, Medicaid, and Marketplace programs, which together provide health coverage to one in three Americans and likely pays for the majority of care that occurs in most health care communities across the nation. 

There’s an old joke at CMS that if you find yourself in a tense conversation, you can usually diffuse it by saying, “Well, my mom is a Medicare beneficiary.” Inevitably, the other person will say, “Mine too.” And, from that shared sense of responsibility, you can go forward from the right place – one that is focused on figuring out what's right for the beneficiaries we serve. 

That is because Medicare is a uniquely American promise. One that – for more than a half-century – has said to all Americans that as you get older, or if you have a disability, you will be able to access care, and your family won't go broke in the process. Before Medicare, do you know how many seniors in this country lived in poverty? One in three.... One in three. Today, it’s less than one in ten. Our promise to the millions of Americans –our neighbors -- particularly when we are living on a low or fixed income-- is part of what has made us who we are. 

Medicare is what provides your parents’ health care and if we do our jobs right, one day, your children’s. Think of it. How we make decisions today will allow us and our children to one day put that Medicare card in our wallets to keep us secure. 

So how are we doing to advance Medicare to keep its promise? 

Since the passage of the ACA, over the last 8 years, together, we have made significant progress in cost and quality and in evolving to meet the new shape of health care.

·         Today, 30% of fee-for-service Medicare payments flow through alternative payment models, up from essentially none in 2010. And, millions more are covered through innovative Medicare Advantage programs. 

·         Quality and safety have improved with the rate of hospital-acquired conditions declining by 17%, which has prevented an estimated 87,000 deaths over 4 years. The rate at which Medicare patients are readmitted to the hospital within 30 days after discharge has decreased sharply, resulting in 565,000 fewer total readmissions. 

·         Medicare provides more access with new prescription benefits and, thanks to the Affordable Care Act (ACA), we’ve closed the Medicare donut hole and with that, 11 million beneficiaries have saved an average of more than $2,000.  

·         The CMS Innovation Center, which the ACA created, takes best practices from the clinical field and has developed over 30 alternative payment models and initiatives, serving millions of Medicare beneficiaries. The CBO expects the Innovation Center to reduce federal spending by about $34 billion over the next 10 years as we find new and better ways to care of people. 

·         And, with all of this, we have been spending tax payer resources more wisely with extended record low medical inflation. The ACA extended the life of the Medicare trust fund and has helped deliver $473 billion in savings. 

Of course, there has been enormous progress extending beyond Medicare: 

·         20 million people now have health insurance who didn’t have it before the ACA (and I am sure you understand that affordable coverage for every American helps keep Medicare costs low. A 62-year old who has affordable coverage and can manage or prevent a chronic disease will be much healthier and less costly when they enter Medicare three years later.) 

You have heard the 20 million stat before. But the effects are much more profound in the everyday life and health of people. 

·         Since the ACA went into effect in 2014, more people now have a personal physician (increase of 3.5%) and easy access to medicine (increase of 2.4%). 

·         Just yesterday, the CDC reported that families struggling to pay medical bills dropped from about 21% in 2011 to 16% in the first half of 2016. 

·         There have been substantial decreases in the share of people who are unable to afford care (decrease of 5.5%) reporting fair or poor health (decrease of 3.4%). 

·         The Medicaid coverage expansion has improved the financial security of the newly insured (for example, by reducing the amount of debt sent to a collection agency by an estimated $600 to $1000 per person gaining Medicaid coverage).  

·         States that expanded Medicaid also saw their hospitals reduce debt by about 13%; 10% more than in states that didn’t expand Medicaid. As former Arizona Governor Jan Brewer said, “I don’t know how you could deliver that population any more services better, more cheaply, than what we’ve already done here,” when asked about her state’s Medicaid expansion. 

If you don’t think this progress has made a major difference in the day-to-day lives of all Americans, you have been paying more attention to politics than people. In fact, there hasn't been a greater stretch of progress in our nation's history as measured by the amount of positive change that has impacted people and their lives and our path to a sustainable future as in the last 8 years.  

But this progress should only be the start if we are to fulfill the real promise of caring for people in our country and doing it in a way that reduces the overall burden of the health care system. 

Today, taxpayers spend over $500 billion each year for the Medicare program. The question that needs to be addressed head on is how Medicare will continue to control costs in the face of a demographic boom as over 10,000 Americans enter Medicare each day, rising demand for health care's new cures and technologies; and an epidemic of chronic disease. 

This is an important way to understand the context behind MACRA. 

To build on the foundation we have begun on reforming the delivery system so that value based care can reach every community in America. Given this magnitude of change, I asked the team to approach MACRA differently. After this historic legislation passed, the CMS team was eager to get to work on implementation. But they heard something different from me. Stop writing, get out of DC, and start listening. 

Through 4,000 formal comments, nearly 100,000 attendees at our events across the nation, focus groups, design sessions, workshops, physician office visits (and countless tweets), we got to hear patients and clinician points of view on things we can do to make healthcare better for them. 

·         We heard the deep dedication that both patients and clinicians have to the Medicare program, but also the many frustrations. 

·         We heard from clinicians who challenged us to prove that MACRA and the Quality Payment Program wasn’t one more check-the-box program and instead allows them to focus on care and quality improvement 

·         We heard from physicians who are fed up that their EHRs do not support patient care. Clinicians want technology that make their jobs easier, match their workflows, and give them access to needed data.  

·         We heard patients who were tired of lugging around or repeating their treatment history -- who wanted more time with a physician who knows them personally, so that they can get the right treatment at the right time without unneeded repetition or miscommunications. 

Our challenge isn't about accountability or quality or costs or whatever euphemism people use. It's to recognize that the path forward isn't through any one model or new three-letter acronym or quick fix, but by addressing the basic things, which lead to bad outcomes, physician burnout, or for patients, particularly needier ones, to feel displaced and not get the right care.  

Your opportunity with MACRA isn't to implement a new scorekeeping system. If we do that, we will not only miss the opportunity to transform, but we will add complexity to an already overly complex system. 

Based on what we heard, we made major changes to how we approached this program holistically.  

First, we focused on a lighter touch and less regulation. By adopting the idea that if we simplified and reduced what was measured and gave physicians back more time with patients and instead supported their quality efforts, we would make more progress. And, we reduced the number of requirements in half to help level the playing field for small or independent practices.  

Second, we came to realize MACRA is many clinicians’ first experience with reporting and paying for quality for the first time. We created multiple timelines to allow clinicians to pick their own pace of entry and development. 

Third, we also recognize that many practices are advanced and ready to go further, so we built more opportunities for clinicians and to allow more innovative models to flourish. We estimate that about 25% of eligible Medicare clinicians will be in an Advanced Alternative Payment Models by 2018, and we have a goal of creating options for physicians in all specialties and geographies in order to allow them to pick models that are right for them.  

As we move forward, we all need to keep building on what works while systematically demanding improvement where we can do better. 

So how do I suggest we tackle the next opportunities?

One. Build from a foundation of progress, not head backwards. There can be no delivery system reform without building on the foundation of reaching universal coverage. That means building on the record 20 million people who have newly found coverage and continuing the security and protections Americans have found, including no-cost preventive care, the elimination of lifetime and annual coverage limits, and the end of pre-existing condition exclusions. If we want to fix how care is delivered, so that we’re providing value, then we must ensure that Americans can afford and access quality care at every point in their lives. If we lose even some of the coverage gains made under the ACA, or leave people in limbo, people will lose access to regular care and we will drive up long-term costs. This doesn't mean we shouldn't improve how coverage works in a bipartisan fashion. We must always do that and we should now as new leaders bring new approaches and solicit new ideas.   

Two. Insist that modernization of Medicare must actually mean modernization. Progress is achieved by ingenuity, innovation, teamwork, and the use of data and technology, not by changing funding formulas.  

I’ll say this bluntly: MACRA can't work as well without a CMS Innovation Center that can move quickly to develop and expand new approaches to paying for care. With changes to the Innovation Center, the advanced alternative payment approaches could slow significantly. We will have a much narrower path with fewer specialty options and approaches, which take in patient and physician feedback. Medicare and commercial payers would then fall further out of alignment, and more importantly, less patients would have access to innovative care methods.  

Three. Start to demand technology that can exchange data, that supports care, and that is affordable. MACRA is an opportunity to move the focus away from paperwork and reporting and towards paying for what works. For a variety of reasons, EHRs became an industry before they became a useful tool. The technology community must be held accountable by their customers and make room for new innovators and to give clinicians more freedom and more flexibility to focus on their patients, to practice medicine, and deliver better care. We worked alongside physicians to design technology tools (QPP.cms.gov) and a support center that allows physicians to learn about, access, and even design their involvement in the Quality Payment Program.  

Four. Don’t forget that people are the heart of every policy made. We are on a journey as a nation towards better health for all. Patients. Care givers. Consumers. You know them better than anyone because you care for them. View MACRA as a step in the journey to develop care together. 

With 50 days to go, I want to close by thanking everyone who has provided the often tough but critical feedback that has helped CMS do our jobs better -- and that have helped me by sharing the realities of what really matters. The CMS team is committed to being your partner, to being transparent, to leading and delivering a path to better care. Remind us that your mother, and any mother are at the center of every decision we make, and we will be too. 

CMS Releases 2015 National Health Expenditures

CMS NEWS

FOR IMMEDIATE RELEASE
December 2, 2016

 

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

 

 

 

CMS Releases 2015 National Health Expenditures

 

In 2015, per-capita health care spending grew by 5.0 percent and overall health spending grew by 5.8 percent, according to a study by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS) published today as a Web First by Health Affairs. Those annual rates continue to be below the rates of most years prior to passage of the Affordable Care Act. And, even as millions of people gained coverage, per-enrollee spending growth in private health insurance and Medicare continue to be well below the average in the decade before passage of the Affordable Care Act.

 

The report concludes that 2015 expenditure growth was primarily the result of increased use and intensity of services as millions gained health coverage, as well as continued significant growth in spending for retail prescription drugs. Spending on prescription drugs increased 9.0 percent in 2015, lower than the 12.4 percent growth in 2014, yet significantly higher compared to 2.3 percent growth in 2013. On a per-enrollee basis, overall spending increased by 4.5 percent for private health insurance, 1.7 percent for Medicare, and 3.8 percent for Medicaid.

 

"Our significant progress in reducing the nation's uninsured rate, while providing strong protections for Americans if they get sick, would not be possible without the Affordable Care Act," said CMS Acting Administrator Andy Slavitt. "As millions more Americans have obtained health insurance, per-person cost growth remains at historically modest levels."  

 

The report noted that over a two-year period, 20.0 million individuals either gained private health insurance coverage or enrolled in the Medicaid program, primarily as the result of the Affordable Care Act. The share of the population with health coverage increased from 86.0 percent in 2013 to 90.9 percent in 2015.

 

Health care spending grew 2.1 percentage points faster than the overall economy in 2015, resulting in a 0.4 percentage-point increase in the health spending share of gross domestic product (GDP) – from 17.4 percent in 2014 to 17.8 percent in 2015. In the decade prior to the passage of the Affordable Care Act (2000-2009), health care spending increased 2.8 percentage points faster than GDP, on an annual average basis.

 

Additional highlights from the report:

 

• Total per-enrollee private health insurance spending increased by 4.5 percent in 2015, compared to average growth in per-enrollee spending of 7.4 percent during 2000-2009. Overall, private health insurance expenditures (33 percent of total health care spending) reached $1.1 trillion in 2015, and increased 7.2 percent in 2015. The faster rate of growth reflected increased enrollment in private health insurance associated with coverage expansions under the Affordable Care Act, and a notable increase in the enrollment in employer-sponsored plans.
• Per-enrollee Medicare spending increased by 1.7 percent, about the same rate as in 2014 and below the average annual growth in per-enrollee spending during 2000-2009 of 7.0 percent (or 5.8 percent when Medicare Part D, which was implemented in 2006, is excluded). Medicare spending, which represented 20 percent of national total health care spending in 2015, grew 4.5 percent to $646.2 billion, slightly slower than the 4.8 percent growth in 2014 even as the leading edge of the baby boom generation joined Medicare. The 2015 rate of growth reflected mixed trends among services compared to 2014 as Medicare hospital spending growth slowed and nursing home and home health care spending grew faster. Medicare prescription drug spending continued to grow by double digits with an 11.0 percent increase in 2015 following a 14.5 increase in 2014.
• Overall Medicaid spending and enrollment grew at a slower rate in 2015 than in 2014 with per-enrollee Medicaid spending increasing 3.8 percent. Medicaid spending, which totaled $545.1 billion, accounted for 17 percent of total spending on health care. Similarly, growth in Medicaid enrollment slowed to 5.7 percent in 2015, significantly lower than the 2014 increase of 11.1 percent.
• Out-of-pocket spending ($338.1 billion), which includes direct consumer payments such as copayments, deductibles, and spending not covered by insurance, excluding premiums, grew 2.6 percent in 2015, compared to average annual growth in out-of-pocket spending during 2000 and 2009 of 4.6 percent. From 2008 through 2015, average annual growth of out-of-pocket spending was 1.9 percent, lower than the average annual growth in overall health spending of 4.3 percent during that same time period. As a result, the share of out-of-pocket spending of total health expenditures fell from 13 percent in 2007 to 11 percent in 2015.
   
• Retail prescription drug spending continued to outpace overall health expenditure growth in 2015, increasing 9.0 percent to $324.6 billion after rising 12.4 percent in 2014. Growth in prescription drug spending was faster than that of any other service in 2015. Recent rapid growth was due to increased spending for new medicines (particularly for specialty drugs such as those used to treat hepatitis C), price growth in existing brand-name drugs, increased spending on generics, and a decrease in the number of expensive blockbuster drugs whose patents expired.
   
• In 2015, the federal government and households accounted for the largest shares of spending (29 percent and 28 percent respectively), followed by private businesses (20 percent), and state and local governments (17 percent).

The CMS Office of the Actuary’s report will appear on the CMS website at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html. 

An article about the study is also being published by Health Affairs as a Web First (http://content.healthaffairs.org/lookup/doi/10.1377/hlthaff.2016.1330) and will also appear in the journal’s January issue.

Healthcare Spending Averaged $5,141 Per Capita in 2015

The Health Cost Institute recently released a study on healthcare cost and utilization in 2015. Here are some key findings from the report:

•	Health care spending averaged $5,141 per individual in 2015.
•	Out-of-pocket spending rose 3% in 2015, to an average of $813 per capita.
•	Prices for services and prescription drugs increased between 3.5-9% in 2015.
•	Women of all ages spent $236 more out-of-pocket than men.
•	In 2015, $649 per capita was spent on brand prescriptions.
•	The price of an ER visit jumped 10.5% to an average of $1,863 in 2015.

Source: Health Cost Institute, November 22, 2016

Fix for stranded HealthCare.gov users may cost agents

Managers say they will conduct three big auto re-enrollment waves

Dec 02, 2016 | By Allison Bell

The November auto re-enrollment wave affected enrollees who were shifted to plans from a different issuer, officials say. (Photo: Screenshot)

Managers of HealthCare.gov have confirmed that they are leaving agent and broker compensation concerns out of efforts to help exchange users facing potential coverage gaps.

HealthCare.gov has developed an "auto re-enrollment" process for users affected by issuer decisions to drop specific health plans. If a consumer's plan goes away, and the consumer fails to choose a replacement plan, the exchange system will try to move the consumer, or move the consumer into a similar plan from the same issuer. HealthCare.gov calls that process "crosswalking."

If an issuer has left the HealthCare.gov system in the consumer's areas, the exchange will try to crosswalk the consumer into a similar plan from a different issuer.

One of the secret to fighting health care costs might, actually, be you.

Some agents and brokers who have struggled to help consumers sign up for HealthCare.gov coverage have been wondering whether the exchange will do anything to increase the odds that the replacement plans will pay commissions to the agents or brokers of record.

HealthCare.gov managers said Nov. 16, during a private conference call with HealthCare.gov agents and brokers, that they will not.

HealthCare.gov "does not take into consideration whether an issuer pays a commission when auto-renewing consumers," exchange managers said, according to a written version of the answer posted on an exchange technical assistance website.

The HealthCare.gov managers talked about one rule that could help exchange plan agents: If HealthCare.gov moves an agent's clients into new plans, and the issuers of the new plans do pay commissions, the issuers of the new plans can pay the commissions to the agent even if the agent's exchange registration has expired.

Managers said, in a separate meeting slidedeck, that they have planned three major auto re-enrollment waves.

The re-enrollment waves

The first, which started Oct. 12, affected enrollees who were being moved into new plans from the same issuer.

The second, which started Nov. 21, affected enrollees who were being moved into new plans from a different issuer.

The third, which will take place this month, will affect enrollees with a variety of more complicated problems, such as problems with clearing up questions about tax credit subsidy applications.

When HealthCare.gov moves enrollees into new plans, HealthCare.gov will "generally" send the agents' producer numbers to the issuers of the new plans, managers said.

"Enrollment information will not be visible in consumers' accounts until Dec. 16," managers said.

Open enrollment for 2017 started Nov. 1 and is set to end Jan. 31.

Drafters of the Affordable Care Act created the public health insurance exchange system, or web-based health insurance supermarket, in an effort to cut the average ratio of claims per enrollee enough to make selling coverage without medical underwriting financially sustainable.

ACA drafters were hoping the exchange system, and exchange system premium subsidies, would tempt enough young, healthy people to buy coverage to offset the cost of requiring insurers to cover people with cancer, severe heart disease, hemophilia and liver failure at standard rates.

The U.S. Department of Health and Human Services set up HealthCare.gov to provide exchange services in states that are unwilling or unable to provide exchange services themselves.

This year, many big, for-profit issuers that lost money on exchange plans in 2015 have decided to pull out of the HealthCare.gov system in many counties in 2017.

Agents and brokers have complained that even some of the issuers that will keep their products on the HealthCare.gov shelves will not pay commissions in 2017, and that some issuers have failed to pay the commissions owed for 2016 sales or earlier sales.

California v. HealthCare.gov

Managers of the state-based ACA exchanges in some states have supported agents' efforts to enforce compensation agreements, and even to impose minimum agent and broker exchange plan sales compensation standards.

In California, for example, Covered California has lobbied for national exchange agent compensation standards and set minimum standards for its own issuers.

HealthCare.gov managers have allowed issuers to pay commissions but have repeatedly said that they will not set payment standards, or help agents and brokers enforce existing compensation agreements.

HealthCare.gov does require issuers to offer the same compensation levels inside and outside the exchange system, and agents and brokers can ask HealthCare.gov for help with compensation-level differences, HealthCare.gov managers said during the conference call meeting.

http://www.lifehealthpro.com/2016/12/02/fix-for-stranded-healthcaregov-users-may-cost-agen?eNL=584056a9140ba0a5463084f1&utm_source=LHPro_Daily&utm_medium=EMC-Email_editorial&utm_campaign=12052016&page_all=1

VA Beneficiaries with Cancer Pay $2,367 Out-of-Pocket Annually

Researchers at Johns Hopkins recently published a study on out-of-pocket spending for cancer patients. Here are some key findings from the report:

 

•	Out-of-pocket costs range from $2,116 to $8,115 for Medicare cancer patients.
•	Medicare covers 80% of outpatient costs, has $1,000 co-pays for hospital visits.
•	Out-of-pocket costs were $2,116 annually for Medicaid beneficiaries with cancer.
•	VA beneficiares paid $2,367 out-of-pocket for care with a new cancer diagnosis.
•	10% reported that those costs were at least 63% of annual income.
•	Hospitalizations accounted for 12-46% of out-of-pocket cancer spending.

Source: Johns Hopkins, November 23, 2016

1.4 Billion Part D Prescriptions Were Dispensed in 2014

ProPublica recently analyzed Medicare Part D prescription data from 2014. Here are some key findings from the report:

•	In 2014, there were 37.1 million Medicare beneficiaries with Part D claims.
•	1.4 billion Medicare Part D prescriptions were dispensed.
•	The retail price of Part D prescriptions in 2014 was $121.5 billion.
•	The average Part D beneficiary had 38 prescriptions in 2014.
•	$85.82 was the average retail price of a prescription.
•	1.35 million providers prescribed drugs to Medicare Part D beneficiaries in 2014.

 

Source: ProPublica, November 17, 2016