Medicare

The Centers for Medicare and Medicaid on Thursday unveiled a 73-page plan to modernize its computer and data systems, as required by the healthcare reform law.

The plan aims to help the massive agency, which pays about $800 billion in healthcare benefits to 100 million Americans every year, drive the transformation of the U.S. healthcare system into one that pays for quality rather than quantity of care.

The agency, according to a summary of the plan, "is focusing efforts on two fronts: to obtain more robust analytics for quality of care in light of new health care delivery models and drive quality improvements by rewarding health care providers based on quality performance metrics."

To achieve those goals, the plan calls for CMS to establish an "enterprise-level capability to capture and analyze data on resource utilization, health outcomes, and cost, even as the volume and scale of its programs and data rapidly increase."

The bill passed the House by voice vote but died in the Senate this week after anonymous Republicans placed a hold on the legislation.

Skilled nursing facilities have been charging Medicare for more therapy and daily care over the past few years even though "beneficiary characteristics remained largely unchanged," according to a new report.

The Health and Human Services Department's Office of Inspector General in particular found that payments for "ultra high therapy" — the highest level of therapy, with the highest per diem rates — increased 90 percent from 2006 to 2008 ($5.7 billion to $10.7 billion). Also, the report found that for-profit facilities were "far more likely than nonprofit or government" facilities to bill for higher paying categories of care, and "a number" of facilities had "questionable billing" in 2008.

The report makes four recommendations to the Centers for Medicare and Medicaid Services: 

• monitor overall payments to skilled nursing facilities and adjust rates, if necessary;
• change the current method for determining how much therapy is needed to ensure appropriate payments;
• strengthen monitoring of facilities that are billing for higher-paying payment categories; and
• follow up on the facilities identified as having questionable billing. 

The report adds that the agency agrees with three of the four recommendations. The agency did not concur with the recommendation to change the current method for determining how much therapy is needed but stated it is committed to pursuing additional improvements to the payment system.

The Medicare agency and Senate Finance Committee leaders are calling for new guidelines on Medicare quality-of-care reviews after a new report said that federal dollars may be going to waste.

The Centers for Medicare and Medicaid Services (CMS) is unable to determine if Medicare quality-of-care budgets are excessive because CMS does not provide specific guidance on how much data should be recorded on quality reviews, according to a Government Accountability Office (GAO) report released Wednesday.

Medicare enters into three-year contracts with Quality Improvement Organizations (QIOs) in all 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands to review whether Medicare-financed medical services meet professionally recognized standards of care. The CMS QIO budget totals about $1.1 billion through July 31, 2011, with about one-fifth going toward reviews, including quality-of-care reviews.

“Without consistent information on the volume and costs for quality of care reviews, CMS cannot ensure that the budget for these reviews [...] for each QIO is appropriate,” the GAO report said.

A 2006 Institute of Medicine Report and a 2008 CMS report both identified weaknesses in CMS’s ability to compare costs across QIOs. CMS said it would work to implement GAO’s recommendations.

“The money we spend to ensure quality healthcare should make people healthier, and effective budget guidelines from Medicare will certainly contribute to making sure we meet that goal,” said Senate Finance Committee Chairman Max Baucus (D-Mont.)

“CMS has to do a better job of tracking this work so it can pay the appropriate amount and so taxpayers get what they’re paying for, which is better quality of care for Medicare beneficiaries,” said ranking member Chuck Grassley (R-Iowa).

State-based programs that help spread the word about Medicare benefits will have to increase beneficiaries' awareness about benefits of the healthcare reform law in order to get federal grants next year, the Medicare agency announced Thursday. 

Fiscal 2011 grants for State Health Insurance Assistance Programs will require that beneficiaries be made aware of "certain provisions" in the law, including "new Medicare prevention and wellness benefits, fraud initiatives, including how beneficiaries can help with fraud detection and reporting, and annual election period changes for 2011."

The programs provide one-on-one counseling, information, education and outreach to help beneficiaries understand their Medicare benefits.

The Centers for Medicare and Medicaid Services made $45 million in grants and support contracts available to 54 programs in 2010, and expects that all of them will reapply in 2011. Applications are due Feb. 16, 2011.

The Obama administration will invest in new technology to prevent wasteful and fraudulent payments in federal health programs, officials said Thursday.

The Centers for Medicare and Medicaid Services will issue a solicitation for fraud-fighting analytic tools to help the agency predict and prevent potentially improper payments before they occur, Health and Human Services Secretary Kathleen Sebelius and Attorney General Eric Holder announced during a healthcare fraud prevention summit in Boston.

HHS said it is exploring systems similar to the predictive modeling tools used by banks and other companies to identify potential fraud before it occurs. The technology will help CMS prevent bad actors from enrolling as care providers or suppliers, HHS said.

CMS said it is already starting to take administrative action to stop fraudulent payments before they are made, instead of chasing down payments after they have been made.

“By using new predictive modeling analytic tools we are better able to expand our efforts to save the millions — and possibly billions — of dollars wasted on waste, fraud and abuse,” CMS Administrator Donald Berwick said in a statement.

The new healthcare reform law also provided an additional $350 million over the next 10 years to fight fraud and abuse. It also toughens sentencing for criminal activity, enhances screening and enrollment requirements and expands overpayment recovery efforts.

The Senate Finance Committee is working on several Medicare payment updates that it hopes to pass by unanimous consent before year's end, congressional and lobbyist sources tell The Hill.

Nothing has been decided, however, and a Republican Finance Committee aide said Wednesday that "the latest from our end is that there isn't a package."

"We're looking at consensus provisions that didn’t make it in [last week's year-long 'doc fix' bill] that are worthy of consideration before we close up shop," the aide told The Hill. "No decisions of substance or process have been made."

The office of Finance Committee Chairman Max Baucus (D-Mont.) refused to comment. 

Provisions under consideration, according to lobbyists tracking the issue, include:

• An adjustment to payments for end-stage renal disease treatment;

• An adjustment to payments for Community Health Centers;

• A demonstration program for reimbursements for intravenous immune globulin; 

• A formula change to cancer hospital reimbursements;

• A hospice regulatory provision;

• A retro-active adjustment to Medicare's geographic pricing index; and

• A fix to federal funding for Graduate Medical Education and teaching hospitals.

The combined provisions could add up to more than $200 million, according to lobbyists.

Doctors are asking the Medicare agency to quickly explain how it will dole out $200 million in overdue reimbursements following “a highly disruptive year" for physician payments.

Healthcare reform enacted this year called on the Centers for Medicare and Medicaid Services (CMS) to reimburse doctors retroactively to Jan. 1, 2010, on several provisions, including extending the floor for a Medicare payment scale used to determine relative costs of practicing medicine in specific locations. Some states were set to receive significant increases due to changes in the scale, according to the Friday letter signed by more than 100 physicians groups.

The Medicare and Medicaid Extenders Act of 2010, which provided a one-year delay in a scheduled cut to Medicare physician rates, included $200 million to process the payment increases, the letter said.

The letter said uncertainty surrounding Medicare physician payments was disruptive to doctor practices. Congress enacted stopgap measures to delay scheduled cuts to Medicare payments several times this year, and on three occasions, temporary cuts went into effect.

“The payment uncertainties and delays were highly disruptive,” the letter said. “Many practices were forced to seek loans to meet payroll expenses, lay off staff or cancel capital improvements and investments in electronic health records and other technology.”

Further, the final 2010 fee schedule undervalued some cardiology codes due to a CMS calculation error, the letter said. Most of the claims have not been adjusted, and some were 40 percent lower than they should have been, the letter said.

Liberal groups issued policy recommendations Monday morning on how to manage care for a typically costly population of so-called “dual eligibles” — people who qualify for both Medicare and Medicaid.

Because of generally poorer health and greater needs for high-cost services, the country's 8.8 million dual eligibles are the most expensive population within the Medicare and Medicaid programs and the most difficult to coordinate care for, according to a report issued Monday morning by the Center for American Progress and Community Catalyst.

According to the report, dual eligibles make up 18 percent of Medicaid enrollees but consume 46 percent of program spending. Meanwhile, they comprise 16 percent of Medicare enrollees but consume 25 percent of spending.

The healthcare reform law includes a number of provisions aimed at improving care coordination for dual eligibles, including a new Federal Coordinated Health Care Office within the Centers for Medicare and Medicaid Services. The new Center for Medicare and Medicaid Innovation at CMS, which will test payment and service delivery models, will benefit dual eligibles, the groups said.

The policy paper calls on the federal government and states to pursue new opportunities for managing dual eligibles that focus on five principles: start with a well-designed healthcare delivery system; ensure strong beneficiary protections; engage dual eligibles and their families in program design; ensure combined Medicare/Medicaid funds to enhance healthcare delivery; and establish a culture of quality improvement.

The public wants Congress to slash the federal deficit — but not at the expense of entitlements, including health programs and Social Security, according to a Bloomberg National Poll released Friday morning.  

Eighty-two percent of respondents opposed Medicare cuts, but there was some support for reforming the system. About half of Republicans said they want to see Medicare and Social Security preserved in their current states.

Almost three-fourths (72 percent) opposed reducing Medicaid benefits for low-income people. Even 66 percent of Tea Party supporters, despite their passion for smaller government, opposed Medicaid reductions.

Support for retaining the Social Security structure was less strong, at 55 percent. Lower-income earners, in particular, favored the current system, the poll said.

The poll was taken Dec. 4-7, just after President Obama's debt commission released its final report recommending reductions in Medicare and Social Security to achieve long-term financial stability.