(CMS-10062) Collection of Diagnostic Data from Medicare Advantage Organizations for Risk Adjusted Payments

DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Centers for Medicare & Medicaid

Services

[Document Identifiers: CMS–R–70, CMS–R–

72, CMS–R–247, CMS–10287, CMS–R–43,

CMS–855(POH), CMS–2552–10, and CMS–

10062]

Agency Information Collection

Activities: Proposed Collection;

Comment Request

AGENCY: Centers for Medicare &

Medicaid Services, HHS.

In compliance with the requirement

of section 3506(c)(2)(A) of the

Paperwork Reduction Act of 1995, the

Centers for Medicare & Medicaid

Services (CMS) is publishing the

following summary of proposed

collections for public comment.

Interested persons are invited to send

comments regarding this burden

estimate or any other aspect of this

collection of information, including any

of the following subjects: (1) The

necessity and utility of the proposed

information collection for the proper

performance of the agency’s functions;

(2) the accuracy of the estimated

burden; (3) ways to enhance the quality,

utility, and clarity of the information to

be collected; and (4) the use of

automated collection techniques or

other forms of information technology to

minimize the information collection

burden.

1. Type of Information Collection

Request: Reinstatement with a change of

a previously approved collection; Title

of Information Collection: Information

Collection Requirements in HSQ–110,

Acquisition, Protection and Disclosure

of Peer review Organization Information

and Supporting Regulations in 42 CFR,

Sections 480.104, 480.105, 480.116, and

480.134; Use: The Peer Review

Improvement Act of 1982 authorizes

quality improvement organizations

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Federal Register /Vol. 78, No. 91 / Friday, May 10, 2013 /Notices 27401

(QIOs), formally known as peer review

organizations (PROs), to acquire

information necessary to fulfill their

duties and functions and places limits

on disclosure of the information. The

QIOs are required to provide notices to

the affected parties when disclosing

information about them. These

requirements serve to protect the rights

of the affected parties. The information

provided in these notices is used by the

patients, practitioners and providers to:

obtain access to the data maintained and

collected on them by the QIOs; add

additional data or make changes to

existing QIO data; and reflect in the

QIO’s record the reasons for the QIO’s

disagreeing with an individual’s or

provider’s request for amendment.:

Form Number: CMS–R–70 (OCN: 0938–

0426); Frequency: Reporting—On

occasion; Affected Public: Business or

other for-profits; Number of

Respondents: 400; Total Annual

Responses: 21,200; Total Annual Hours:

42,400. (For policy questions regarding

this collection contact Coles Mercier at

410–786–2112. For all other issues call

410–786–1326.)

2. Type of Information Collection

Request: Reinstatement without change

of a previously approved collection;

Title of Information Collection:

Information Collection Requirements in

42 CFR 478.18, 478.34, 478.36, 478.42,

QIO Reconsiderations and Appeals; Use:

In the event that a beneficiary, provider,

physician, or other practitioner does not

agree with the initial determination of a

Quality Improvement Organization

(QIO) or a QIO subcontractor, it is

within that party’s rights to request

reconsideration. The information

collection requirements at 42 CFR

478.18, 478.34, 478.36, and 478.42,

contain procedures for QIOs to use in

reconsideration of initial

determinations. The information

requirements contained in these

regulations are imposed on QIOs to

provide information to parties

requesting the reconsideration. These

parties will use the information as

guidelines for appeal rights in instances

where issues are actively being

disputed. Form Number: CMS–R–72

(OCN: 0938–0443); Frequency:

Reporting—On occasion; Affected

Public: Individuals or Households and

Business or other for-profit institutions;

Number of Respondents: 2,590; Total

Annual Responses: 5,228; Total Annual

Hours: 2,822. (For policy questions

regarding this collection contact Coles

Mercier at 410–786–2112. For all other

issues call 410–786–1326.)

3. Type of Information Collection

Request: Reinstatement with a change of

a previously approved collection; Title

of Information Collection: Expanded

Coverage for Diabetes Outpatient Self-

Management Training Services and

Supporting Regulations Contained in 42

CFR 410.141, 410.142, 410.143, 410.144,

410.145, 410.146, 414.63; Use:

According to the National Health and

Nutrition Examination Survey

(NHANES), as many as 18.7 percent of

Americans over age 65 are at risk for

developing diabetes. The goals in the

management of diabetes are to achieve

normal metabolic control and reduce

the risk of micro- and macro-vascular

complications. Numerous epidemiologic

and interventional studies point to the

necessity of maintaining good glycemic

control to reduce the risk of the

complications of diabetes. Despite this

knowledge, diabetes remains the leading

cause of blindness, lower extremity

amputations and kidney disease

requiring dialysis. Diabetes and its

complications are primary or secondary

factors in an estimated 9 percent of

hospitalizations (Aubert, RE, et al.,

Diabetes-related hospitalizations and

hospital utilization. In: Diabetes in

America. 2nd ed. National Institutes of

Health, National Institute of Diabetes

and Digestive and Kidney Disease, NIH,

Pub. No 95–1468–1995: 553–570).

Overall, beneficiaries with diabetes are

hospitalized 1.5 times more often than

beneficiaries without diabetes. HCFA–

3002–F ‘‘Expanded Coverage for

Outpatient Diabetes Self-Management

Training and Diabetes Outcome

Measurements’’, provided for uniform

coverage of diabetes outpatient selfmanagement

training services. These

services include educational and

training services furnished to a

beneficiary with diabetes by an entity

approved to furnish the services. The

physician or qualified non-physician

practitioner treating the beneficiary’s

diabetes would certify that these

services are needed as part of a

comprehensive plan of care. This rule

established the quality standards that an

entity would be required to meet in

order to participate in furnishing

diabetes outpatient self-management

training services. It set forth payment

amounts that have been established in

consultation with appropriate diabetes

organizations. It implements section

4105 of the Balanced Budget Act of

1997. Form Number: CMS–R–247 (OCN:

0938–0818); Frequency: Recordkeeping

and Reporting—Occasionally; Affected

Public: Business or other for-profit

institutions; Number of Respondents:

5327; Total Annual Responses: 63,924;

Total Annual Hours: 197,542. (For

policy questions regarding this

collection contact Kristin Shifflett at

410–786–4133. For all other issues call

410–786–1326.)

4. Type of Information Collection

Request: Extension of a currently

approved collection; Title of

Information Collection: Medicare

Quality of Care Complaint Form; Use: In

accordance with Section 1154(a)(14) of

the Social Security Act, Quality

Improvement Organizations (QIOs) are

required to conduct appropriate reviews

of all written complaints submitted by

beneficiaries concerning the quality of

care received. The Medicare Quality of

Care Complaint Form will be used by

Medicare beneficiaries to submit quality

of care complaints. This form will

establish a standard form for all

beneficiaries to utilize and ensure

pertinent information is obtained by

QIOs to effectively process these

complaints. Form Number: CMS–10287

(OCN: 0938–1102); Frequency:

Reporting—Occasionally; Affected

Public: Individuals or Households;

Number of Respondents: 3,500; Total

Annual Responses: 3,500; Total Annual

Hours: 583. (For policy questions

regarding this collection contact Coles

Mercier at 410–786–2112. For all other

issues call 410–786–1326.)

5. Type of Information Collection

Request: Reinstatement with change of a

currently approved collection; Title of

Information Collection: Conditions of

Participation for Portable X-ray

Suppliers and Supporting Regulations

in 42 CFR Sections 486.104, 486.106,

486.110; Use: The requirements

contained in this information collection

request are classified as conditions of

participation or conditions for coverage.

These conditions are based on a

provision specified in law relating to

diagnostic X-ray tests ‘‘furnished in a

place of residence used as the patient’s

home,’’ and are designed to ensure that

each supplier has a properly trained

staff to provide the appropriate type and

level of care, as well as, a safe physical

environment for patients. CMS uses

these conditions to certify suppliers of

portable X-ray services wishing to

participate in the Medicare program.

This is standard medical practice and is

necessary in order to help to ensure the

well-being, safety and quality

professional medical treatment

accountability for each patient. Form

Number: CMS–R–43 (OCN: 0938–0338);

Frequency: Yearly; Affected Public:

Business or other for-profit and Not-forprofit

institutions; Number of

Respondents: 578; Total Annual

Responses: 578; Total Annual Hours:

948. (For policy questions regarding this

collections contact Alesia Hovatter at

410–786–6861. For all other issues call

410–786–1326.)

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27402 Federal Register / Vol. 78, No. 91 / Friday, May 10, 2013 / Notices

6. Type of Information Collection

Request: New collection (Request for a

new OMB control number); Title of

Information Collection: Annual Report

of Physician-Owned Hospital

Ownership and/or Investment Interest;

Use: Section 6001 of the Affordable Care

Act (ACA) requires Medicare hospitals

to report whether they have any

physician owners including

immediately family members of the

physician.

Currently the CMS 855A captures

basic ownership/managerial information

on providers. The CMS 855A was

revised in July 2011 and a specific

attachment designed to capture

physician-owned hospital ownership

and investment interest data was added

to the form. The attachment is being

removed from the CMS 855A

application because the annual

reporting requirement for physicianowned

hospitals is not required for

Medicare enrollment processing. This

physician-owned hospital data

collection is mandated to be reported on

an annual basis. Additionally, the ACA

prohibits the expansion of current

physician-owned hospitals and banned

the establishment of new ones making

the CMS 855A the improper method to

collect this required annual report.

CMS is requesting the physicianowned

hospital ownership information,

investment information or both,

previously collected in Attachment 1 of

the CMS 855A enrollment application to

become a stand-alone form with a

unique OMB number for the following

reasons:

• The physician-owned data

collection has a small targeted audience

of approximately 140 physician-owned

hospitals nationwide.

• The physician-owned data

collection is required annually, as noted

above.

• The data required under section

6001 is more specific than the data

currently collected on the CMS–855A

provider enrollment application.

• The data is not required for

Medicare provider enrollment purposes.

Form Number: CMS–855 (POH)(OCN:

0938-New); Frequency: Reporting—

Yearly; Affected Public: Private Sector—

Business or other for-profits and not-forprofit

institutions; Number of

Respondents: 140; Total Annual

Responses: 140; Total Annual Hours:

140. (For policy questions regarding this

collection contact Kim McPhillips at

410–786–5374. For all other issues call

410–786–1326.)

7. Type of Information Collection

Request: Revision of a currently

approved collection; Title of

Information Collection: Hospital and

Health Care Complexes and Supporting

Regulations in 42 CFR 413.20 and

413.24; Use: Medicare Part A

institutional providers must provide

adequate cost data to receive Medicare

reimbursement (42 CFR 413.24(a)).

Providers must submit the cost data to

their Medicare Fiscal Intermediary (FI)/

Medicare Administrative Contractor

(MAC) through the Medicare cost report

(MCR). We are submitting a revision of

the Hospital and Hospital Health Care

Complex Cost Report, Form CMS–2552–

10. Form CMS 2552–10 is used by

hospitals participating in the Medicare

program to report the health care costs

to determine the amount of

reimbursable costs for services rendered

to Medicare beneficiaries. The revisions

were caused by legislative requirements

in the Patient Protection and Affordable

Care Act of 2010 and the Temporary

Payroll Tax Cut Continuation Act of

2011. Form Number: CMS–2552–10

(OCN: 0938–0050); Frequency:

Reporting—Yearly; Affected Public:

Private Sector—Business or other forprofits

and not-for-profit institutions;

Number of Respondents: 6,171; Total

Annual Responses: 6,171; Total Annual

Hours: 4,153,083. (For policy questions

regarding this collection contact Nadia

Massuda at 410–786–5834. For all other

issues call 410–786–1326.)

8. Type of Information Collection

Request: Reinstatement with change of a

previously approved collection. Title of

Information Collection: Collection of

Diagnostic Data from Medicare

Advantage Organizations for Risk

Adjusted Payments. Use: CMS will use

the data to make risk adjusted payment

under Parts C. MA and MA–PD plans

will use the data to develop their Parts

C bids. As required by law, CMS also

annually publishes the risk adjustment

factors for plans and other interested

entities in the Advance Notice of

Methodological Changes for MA

Payment Rates (every February) and the

Announcement of Medicare Advantage

Payment Rates (every April). Lastly,

CMS issues monthly reports to each

individual plan that contains the CMS–

HCC and RxHCC models’ output and the

risk scores and reimbursements for each

beneficiary that is enrolled in their plan.

Form Number: CMS–10062 (OMB 0938–

0838). Frequency: Quarterly. Affected

Public: Private Sector (business or other

for-profit and not-for-profit institutions).

Number of Respondents: 766. Total

Annual Responses: 830,000. Total

Annual Hours: 40,650. (For policy

questions regarding this collection

contact Michael Massimini at 410–786–

1566. For all other issues call 410–786–

1326.)

To obtain copies of the supporting

statement and any related forms for the

proposed paperwork collections

referenced above, access CMS’ Web site

address at http://www.cms.hhs.gov/

PaperworkReductionActof1995, or

Email your request, including your

address, phone number, OMB number,

and CMS document identifier, to

Paperwork@cms.hhs.gov, or call the

Reports Clearance Office on (410) 786–

1326.

In commenting on the proposed

information collections please reference

the document identifier or OMB control

number. To be assured consideration,

comments and recommendations must

be submitted in one of the following

ways by July 9, 2013:

1. Electronically. You may submit

your comments electronically to http://

www.regulations.gov. Follow the

instructions for ‘‘Comment or

Submission’’ or ‘‘More Search Options’’

to find the information collection

document(s) accepting comments.

2. By regular mail. You may mail

written comments to the following

address: CMS, Office of Strategic

Operations and Regulatory Affairs,

Division of Regulations Development,

Attention: Document Identifier/OMB

Control Number lll, Room C4–26–

05, 7500 Security Boulevard, Baltimore,

Maryland 21244–1850.

Dated: May 6, 2013.

Martique Jones,

Deputy Director, Regulations Development

Group, Office of Strategic Operations and

Regulatory Affairs.

[FR Doc. 2013–11035 Filed 5–9–13; 8:45 am]

BILLING CODE 4120–01–P

Canadian Healthcare Innovation, the MyMedRec App Goes Global

OTTAWA, ONTARIO -- (Marketwired) -- 05/14/13 --MyMedRec, one of Canada's top free iPhone apps to help people and their families keep track of medication use and immunization history, is now available internationally. MyMedRec
allows users to keep information on their medications and vaccines at their fingertips, ready to share with their healthcare providers.
The personal electronic medication record empowers the growing number of smartphone owners who use mobile devices to manage a wide range of personal data, including their medication information. The World Health Organization has established safe medication use as a priority given that an estimated 50 per cent of patients do not take their medication correctly, while studies have shown that proper adherence to medication improve health outcomes.
Earlier this year, MyMedRec reached the top ten list for free iPhone and iPad apps and has been downloaded by more than 8,000 Canadians. Until now, it was only available in Canada. Consumer requests for the app have come from the U.S, Ireland, Saudi Arabia, and other countries. MyMedRechas received praise from users, health care professionals and app reviewers alike.
"This is a great, innovative app! You are able to keep important medical information with you, ready for use when needed. I especially like the feature where the user is able to photograph and include the label as part of the database for both prescription and natural medications," added Kathleen, who uses the app.
"MyMedRec is a clear, simple and easy to use mobile app. It's a great tool to help people keep a list of not only their prescriptions, but also their vitamins, non-prescription drugs, supplements and immunizations," Kelly Grindrod, Assistant Professor, School of Pharmacy, University of Waterloo and mobile health technology researcher.
MyMedRec was launched in Canada by seven of the country's leading health care organizations to promote adherence and the safe and responsible use of medications and vaccines. Features include a reminder to take a dose or to refill a prescription. MyMedRec is the latest innovation in the "Knowledge is the best medicine" program which was developed in 1994 by Canada's Research-Based Pharmaceutical Companies (Rx&D) as a tool to help Canadians take control of their health and work with their healthcare team to manage medicines safely and appropriately.
"We have been working with our partners to make these tools available because we know that proper adherence to medication leads to healthier outcomes for patients," said Russell Williams, President of Canada's Research-Based Pharmaceutical Companies. "Based on the reaction we have had in Canada and the requests we have received from around the world to make it available globally, we are thrilled to share this tool that we believe everyone can benefit from."
Key Features:

--  Medication and natural products dose reminders 
--  A record of when medicines were taken 
--  A separate archive for medicines the user is no longer taking 
--  Multiple profiles allows the user to keep track of family's health
    information 
--  Easily adds entries to the device's calendar for prescription refills,
    medical appointments and upcoming immunization 
--  Emails parts or all of the user's profile and medication to a healthcare
    provider, as necessary 
--  Additional security with optional separate password and data encryption
    upon locking the device 

The app was developed with the support and collaboration of leading health organizations, including Canada's Research Based Pharmaceutical Companies, Institute for Safe Medication Practices Canada, Canadian Medical Association, Canadian Nurses Association, Canadian Pharmacists Association, Victorian Order of Nurses and Best Medicines Coalition.

From god to guide: can patient-centred care become a reality in the NHS?

Most parts of the NHS are only paying lip service to patient engagement, recently hailed as the 'next blockbuster drug'

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  • Guardian Professional, Tuesday 14 May 2013 03.30 EDT
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Educating patients so that they can make informed choices is vital. Photograph: Suzanne Plunkett/Reuters

As healthcare systems the world over continue to groan under the weight of rising expectations, ageing populations and squeezed finances, the search for viable long-term solutions shows no sign of slowing.

For many, the focus remains on system reform – finding new ways to make the money go further by redesigning services to be more efficient. But, increasingly, attention is turning to the people who use healthcare services as the potential saviour of them.

As Maureen Bisognano, president of the influential US-based Institute for Health Improvement, told the International Forum on Quality and Safety in Health in London in April: "Patient engagement is the next blockbuster drug."

Patient engagement is certainly not a new concept but, in truth, most parts of the NHS are still only paying lip service to it. The default position for many health professionals is still to think in terms of, "What's the matter with you?" rather than, "What matters to you?"

It's easy to see why. Most systems, our own included, are heavily geared towards the five hours a year that, on average, we each consume healthcare. However, ccording to a new report by KPMG, called Something to Teach, Something to Learn: Global perspectives on healthcare, the real gains are being made by health systems that understand the importance of the 8,760 hours a year when we are not officially classed as patients.

Technological advances, such as smartphone apps which can speed a patient's hospital discharge by allowing them to measure ECGs at home, or telemedicine systems, which deliver multidisciplinary virtual clinics, offer a partial solution to empowering patients.

But the reason these breakthroughs have not revolutionised care in the way we thought they might 10 years ago is that a more fundamental issue is being missed – that of understanding a patient's needs beyond treating the condition with which they have been diagnosed. Too often, our systems encourage the health professional to treat the illness, not the person. We chase narrow biomedical indicators, which, while important, don't capture all that matters to the patient.

There's now a great deal of evidence which shows that when patients are asked what they really want, they often choose a different (and in many cases less expensive) course of action to the one their doctor or nurse might have recommended. For example, most patients do not want to spend their last hours in hospital, yet the majority do.

Educating patients so that they can make informed choices, not just about their care but about their overall lifestyles, is vital. But it is also only half the battle. The key is listening to, and acting on, those choices – only then do patients become truly empowered.

And that's where system change comes in. The emerging evidence from around the world, as highlighted in Something to Teach, Something to Learn, is that to thrive in the challenging years ahead, healthcare systems will need to reorient themselves around the needs of patients.

Hospitals will have to look beyond their four walls, bridging the gap with primary care and transforming to become part of health systems, taking responsibility for entire pathways of care.

Primary care will need to become more accessible and more time will need to be given to understanding the needs and expectations of the 3% of patients that drive 50% of NHS costs every year.

These patients, often with multiple conditions, need continuity and access to integrated services which combine primary care, supported by specialists and the effective use of telephone and web-based tools and support. For this to work, health system funding also needs to be reshaped. There are already signs, from around the world, that payers – be they private insurers or governments – are becoming more active.

They are gaining a better understanding of what constitutes quality in the eyes of patients and designing new types of contracts that reward "value" rather than "volume".

ParkinsonNet, a ground-breaking patient-led education programme in the Netherlands, is a great example. It has shifted perceptions about what constitutes value for Parkinson's patients and, as a result, has radically changed practitioner behaviour. The programme has already halved the number of hip fractures suffered by this patient group and delivered savings of £13m.

In a system designed around the patient, clinicians need to move from god to guide, focusing their skills on the provision of information and support to help patients make effective choices and manage their own health and wellbeing.

True patient empowerment is not a bolt-on; it should be the centrepiece of the healthcare jigsaw.

This partnership is pivotal and central to an NHS which delivers both high quality healthcare and value too. Is it possible? With our greatest asset – the hundreds of thousands of front-line NHS staff who work with patients every day – yes, absolutely.

Mark Britnell is chairman of KPMG's global healthcare practice.

This article is published by Guardian Professional.

Responsible Solutions That Protect and Preserve Medicare

Posted on 05/13/2013 by Ian Cunningham  

This is a guest post by Sean Voskuhl – State Director, AARP Oklahoma

Growing up in rural Oklahoma, I saw first-hand the importance of Medicare.  Finding accessible and affordable health care was always very difficult.  Many folks had no choice but to purchase a catastrophic/high deductible plan, or they relied on a spouse to get coverage by taking a job in town, or they went without health insurance at all. Simply put, most people gambled and prayed, trying to hold on till they could get on Medicare.

Today, Medicare is the primary health insurance program for the 49 million Americans who are 65 and older.  Roughly, one in four of those beneficiaries are rural residents, and that number will only rise in coming years.  With changing demographics and rising health care costs, Medicare is facing a number of challenges.  Unfortunately, some in Washington believe the only way to address those challenges is to cut Medicare benefits or force seniors to pay more.  No doubt any such changes to Medicare will greatly impact rural America.

Is there a better way?  What about cracking down on waste, fraud and abuse?  The U.S. health system wastes as much as a third of all spending because of inefficient payment systems, uncoordinated care, duplication, over-testing and unnecessary paperwork.  It’s estimated that Medicare could save hundreds of billions of dollars just by reducing waste.  More could be saved by stepping up fraud detection.  In 2011 alone, anti-fraud efforts recovered $4.1 billion.  In October 2012, Medicare Strike Force operations in seven cities led to charges against 91 individuals-including doctors, nurses and other licensed medical professionals-for their alleged participation in Medicare fraud schemes involving some $432 million in false billing.  And yet we know much more can and should be done.

Here are some other examples of Medicare fraud that may hit closer to home: a healthcare provider bills Medicare for services you never received; a supplier bills Medicare for equipment you never got; someone uses your Medicare card to get medical care, supplies, or equipment; a company offers a Medicare drug plan that has not been approved by Medicare; or, a company uses false information to mislead you into joining a Medicare plan.

If we want to preserve and protect Medicare for future generations, it’s essential to crack down on fraud and abuse.  The resulting savings will cut costs for families, businesses and the federal government, and increase the quality of services for those who need care. But stopping fraud requires the cooperation of everyone-the federal government, state governments, health care providers, insurers, law enforcement, and even people like you and me.

To learn more about the challenges facing Medicare, and hear what you can do to help stop Medicare fraud, tune in to AARP Live on RFD-TV this Thursday, May 16^th at 9p.m. CT on RFD-TV. I’ll be joined by AARP state director Greg Marchildon (VT), AARP senior advisor Pete Jeffries, and AARP Iowa volunteer Maryalice Larson, all of whom have a first-hand view of the challenges facing Medicare. Let’s find responsible solutions that will keep Medicare strong without shifting the burden of higher health care costs onto seniors and future retirees.

Tune in to AARP Live on RFD on Thursday, May 16^th at 9 pm CST to learn more.

Please join me this Thursday night for AARP Live! on RFD-TV, or watch it streaming live at www.aarp.org/rfdand on Facebook

(click here  for “by zipcode” channel locator) Viewers are encouraged to phone in during the show, 888- 687-2277 toll-free, to share your questions/concerns.

Managed Medicare Advantage Plans Demonstrate Better Outcomes for Patients

By Analyzing Insurance Claims From 3 Million U.S. Medicare Patients, The Boston Consulting Group Finds That Managed Private Plans Outperform Traditional Fee-for-Service Medicine on Health Care Quality and Value

BOSTON, MA--(Marketwired - May 14, 2013) - As health systems around the world experiment with alternative models for care delivery and reimbursement to improve health care quality and lower cost, they can learn a lot from the care-delivery models used by private payers in U.S. Medicare Advantage plans, according to a new study by The Boston Consulting Group (BCG).

After analyzing claims data for 3 million Medicare patients, BCG found that on three internationally accepted dimensions of health care quality -- single-year mortality, recovery from acute episodes of care requiring hospitalization, and the sustainability of health over time -- patients enrolled in Medicare Advantage plans offered by private insurers had considerably better outcomes than those participating in Medicare on a traditional fee-for-service basis. The improved quality is delivered on top of the well-understood point that these models already deliver lower costs.

"Our findings demonstrate that the more managed plans do not compromise quality. Just the opposite: they deliver higher-quality care at a lower cost than fee-for-service medicine and thus do a better job of improving health care value," said Jon Kaplan, a BCG partner and lead author of the study. "Payers, providers, and policymakers have a lot to gain by more broadly aligning incentives and delivering strong care management, similar to that utilized by the Medicare Advantage plans."

The findings are detailed in a new report titled Alternative Payer Models Show Improved Health-Care Value, released today on www.bcgperspectives.com.

The majority of the U.S. Medicare-eligible population receive care from doctors and other providers on a traditional fee-for-service basis, with the costs of the services reimbursed directly by Medicare. About one-quarter are enrolled in Medicare Advantage health plans provided by private insurers.

What distinguishes Medicare Advantage plans from traditional fee-for-service plans is the degree to which they use mechanisms designed to encourage the delivery of cost-effective quality care. Three critical mechanisms are financial incentives that are aligned with clinical best practices, a selective network of providers, and more active care management that emphasizes prevention to minimize expensive acute care.

Of the 3 million patients for which BCG analyzed data, approximately 1.3 million used providers on a traditional fee-for-service basis. The remainder were enrolled in one of three types of private Medicare Advantage plans: a preferred provider organization (PPO), a health maintenance organization (HMO), or an HMO with global capitation.

Among the study's specific findings:

   -- Single-year mortality rates fell from 6.8 percent in the traditional fee-for-service sample to 1.8 percent in the three progressively managed delivery models. The lowest rates and the greatest performance were seen in the HMO plans with global capitation. Patients in the three managed models achieved these lower levels of single-year mortality quickly, within the first year of enrollment. 
 
   -- Patients in the Medicare Advantage plans had shorter average stays in the hospital. Compared to the fee-for-service sample, the capitated HMO sample had stays that were, on average about 19 percent shorter. 
 
   -- Patients in the managed plans were more likely to receive preventive care and less likely to suffer from disease-specific complications. For example, diabetic patients in the fee-for-service sample had an average of 11.5 amputations per 1,000 patients; those in HMO plans with global capitation had only 0.3. 

"We've found that U.S. private insurers have created an operating model that can deliver better care at a lower cost and have a major role to play in the ongoing national efforts to improve health care quality," said Stefan Larsson, a BCG senior partner and coauthor of the report. "Quite simply, we've found that the more aligned the care, the better the quality delivered."

Best Opportunities & Biggest Threats in Healthcare

Written by Jim McLaughlin | May 13, 2013

At the Becker's Hospital Review Annual Meeting in Chicago on May 10, a panel of health system executives discussed the greatest opportunities and biggest threats ahead for the healthcare industry. 

Barry Arbuckle, PhD, president and CEO of MemorialCare Health System based in Fountain Valley, Calif.; Daniel Slipkovich, CEO of Franklin, Tenn.-based Capella Healthcare; Sandra Bruce, president and CFO of Chicago-based Presence Health; and Stephen Bonner, president and CEO of Cancer Treatment Centers of America based in Schaumburg, Ill., sat on the panel, moderated by Fox News anchor and former White House correspondent Bret Baier.

Here is an edited transcript of the panelists' discussion:

Bret Baier: What opportunities do you see in the healthcare industry as we move into the first year of health reform?

Stephen Bonner: We need to bring more intelligence into healthcare. We're now moving into a phase of consumers, regardless of what might be set by federal policy, becoming more engaged in their healthcare with more health savings and savvier in how they buy their care. The health reform law and the exchanges are rapidly accelerating that whole structure. It's an unintended consequence, but we're going to end up with more engaged consumers. If we listen, they'll help us deliver cheaper and better care without needing to funnel money through the feds. There's a lot left to be determined, but we think [the U.S. healthcare system] is really missing a major opportunity. We have this incredible capability and capacity, but there's a disconnect between desire and what's available,  and that's not a U.S. phenomenon. Why shouldn't we flip it around and use our excess capacity and invite people to come to the U.S. and improve on that?

Sandy Bruce: Only God knows. We're the largest Medicaid provider in the state, and the exchanges are a big worry for us.  Lots of people will get coverage, but then what happens when they come into our doors without realizing they'll still owe 30 percent of the bill? That'll create a financial burden on providers, if we're not careful. Most of us have grown up building hospitals and filling beds, but that's clearly changed. I think the real opportunities for healthcare lie in the changing revenue streams in different care settings and for different metrics of care. I think we also have a huge opportunity to reduce variation in healthcare. Within my own system of 12 hospitals, we think we could save between 20 and 40 percent by reducing clinical variations among our physicians. [Electronic health records], although they're expensive, can help us achieve that. Another piece I'm particularly concerned about is that a quarter of Americans could be covered by Medicaid in a year. We are oblgated to figure out a way to deliver care to them at a very different cost structure. It can't look like what we've been doing.

Barry Arbuckle, PhD: The upcoming changes are mindboggling in significance. I'm a big fan of complete connectivity and seamless connection to population health. You're fooling yourself if you think you can do population health or keep physicians integrated without it. There are also lots of interesting and creative partnerships being formed between providers that provide benefits of scale but fall short of a full transaction.

Dan Slipkovich: We're repeating a lot of what we did in the 1990s. We're expanding outside our walls and buying other entities, etc., but I'd tell you it's going to stick this time. In the '90s, we simply didn't have the technology to follow through on the initiatives of the time. The trouble for us now is going to be meeting the influx of new patients, many of whom will be covered by Medicaid. Many say hospitals will benefit from more insured patients, but it's going to be a shift to re-spending the same dollar amount on a much broader population. Access is also a big issue. Our emergency department services grew 10 percent last year, but that's because so many patients didn't have anywhere else to go.

Mr. Baier: What looming threats have been keeping you up at night?

Dr. Arbuckle: There are solvency concerns about the Medicaid program, as well as Medicare so long as politicians keep using it as their piggy bank to solve other budget problems. The solution, I believe, is in managed care. It's the only thing that can cause those programs to survive, but it takes infrastructure and experience. Everything is harkening back to the '90s, but I truly believe we're doing it different this time. We have better systems, better technology, even better intentions. Before it was all about money, but now it's survival. We have better regulation now, too. We might actually be successful this time.

Mr. Bonner: The biggest threat is misleading for what we're trying to create and what it'll take to create it. Healthcare has become so politicized, but can we really engage people in the discussions about how to do healthcare better? I think we're failing to engage in the right conversations. We need to connect the will to drive quality to where it belongs and cost what it ought to cost. There's a lack of will to tackle really tough systemic issues, such as primary care. Can we tackle malpractice in this country? Can we tackle transparency? We equip people with the kind of information that JD Power & Associates give to keep them from buying crummy products, but not in healthcare. How do we pretend to be a consumer-driven industry if we can't do that? The greatest clinical opportunities are through innovations in oncology, finding the best balance between safety, efficacy and speed.The cost we can take out of the system and the human cost we can take out in avoiding side effects is astounding.

Ms. Bruce: We believe there's probably overcapacity in hospitals today, and acute care will shrink. Everything's moving into medical home office ambulatory settings. What will become of the capital investments we've all made in patient towers and all the rest over the years. We're struggling on where to place the bets on where the industry is going. We're also starting to worry that our biggest competitor is no longer other large hospital systems but Walgreens and the retail clinics. We're still protecting our big-box assets, while others are coming in who'll get into the new industry better.

Mr. Baier: What do you predict other systems will begin doing to adapt to the changing landscape of healthcare?

Dr. Arbuckle: I have a hard time predicting what's going to happen. There will be changes in resource utilization without a doubt. At the same time, there's a burgeoning population of seniors who will utilize healthcare resources at six times that of the commercial population. We've also got  an obesity epidemic in this country and all the problems that causes. I believe we'll see fewer beds in larger markets as we shift to more population health management in the ambulatory setting. Freestanding, non-profit hospitals historically have had an amazing ability to lose money and hang on for years, and this time, I worry they may not. Now is the time to be exploring partnerships and transaction opportunities of all kinds, not when you're desperate. There's a major problem with staffing resources as well. I have hundreds of open positions that I can't fill, even in this unemployment market. Right now we've got excess capacity in the marketplace, consolidation will drive that excess out. I firmly believe over the next five to eight years, you'll see 500 fewer hospitals in this country. 

Ms. Bruce: The framework of our competition is changing. Consumers are changing rapidly too. If we connect with them, learn what they value and how to deliver that to them, we'll still fill our patient towers, but we don't need to make people come to the big boxes to get their height and weight. There's no need for them to come in if their iPhone can send a high-resolution image of their lesion to a physician who can diagnose and prescribe care remotely. Customers know that, so how can we engage them, and will we get paid to deliver that way? One of my doctors has been doing just that, but hasn't told people about it because he knew it wouldn't produce any RVUs. Johns Hopkins is piloting a stay-home admission model, which is cheaper and minimizes infection risk, but it still has to be approved by payors.

Dr. Arbuckle: I think we'll see a resurrection of worksite clinics, but the only way it can work economically is if there are aligned incentives. We know there is a lot of waste in the healthcare system. I recently learned I have an allergy to beestings. I now get allergy shots twice each week. For those who'd have to leave work to travel to a physician's clinic, wait to be seen, handle the billing and return, that's two hours of work time lost, and twice  per week. The productivity loss is crazy for employers! That's a perfect candidate for a worksite clinic. Obviously we've got a lot of changes and challenges, and for us it starts with people. Everyone should engage their boards and physicians to get the people side  of this right. Beyond that, it's easy to get caught up in the problem of the day. Despite what happens with Medicaid, we know what we have to do — stay very focused.

Mr. Bonner: The fundamental here is to stay clear on our fundamental purpose and who we need to serve. Healthcare is rightfully under the spotlight. The wisdom of the customer coupled with the wisdom of medicine and employers brings us all to a more efficient, more effective delivery of care. We know waiting in hospitals builds stress, wastes time for us and for employers, so last year we took 150,000 hours of patient wait time out of our process. Listen to customers. There's a great future in healthcare in America. A lot of [healthcare executives] have one foot on the dock and one foot in the boat. Call your shots, be courageous and increase your appetite for risk.

The Real Cost of Education, Auditing and Patient Engagement: $5 PMPM

Kameron Gifford, CPC   www.ermconsltinginc.com

Republican, Democrat or Independent; Provider, Patient or Payor, It doesn’t matter what side of the line you fall on – we can all agree on one thing – Healthcare Reform is as necessary as it is Inevitable. We must align ourselves for the paradigm shift that lies ahead. We can’t continue to repeat the same actions over and over again with the expectation of different results? That, by definition, is insanity.

I recently wrote an article, “Mission Critical, Target Missed: $34.1 Billion in Overpayments to MA Plans in 2012” in which I referenced a recent study that found MA plans were (on average) overpaid $2,600 per beneficiary last year. If we break that down month over month we are looking at approximately $200 per month per enrollee. What did MA plans spend that money on in 2012?

How did their enrollee’s experience of care compare to their neighbors who elected to stick with traditional Medicare? And what about the providers who took care of these patients? How did their experience of providing care to MA members compare to those patients with traditional Medicare?

It might surprise you that the answer to that question would fluctuate greatly depending on who you asked, where they lived, what type of care they needed (or provided) and what plan they were enrolled with (or contracted with) last year.

According to the Kaiser Foundation, Medicare Advantage enrollment grew by 10% in 2012, exceeding 13 million enrollees or 27% of the total Medicare population. Of those 13.1 million, only 26% of all Medicare Advantage enrollees were covered by plans that were rated as above average or excellent, and 575,000 enrollees, about 9% were in plans that were “underperforming” and received less than 3 stars.

This is our solution? A solution that is plagued with complex reimbursement systems and unsustainable costs? One in which the access to care has been severely restricted all in the name of cost reduction? A system in which patients with insurance are unable to access the care they need and as a result do not get cost saving, preventive services. A solution that is only providing average care to the majority of our seniors?

We know that the cost of care is directly proportionate to the value it provides, and to be effective, that value must be meaningful to the patient.

So how much money was invested in 2012 by Medicare Advantage plans to close traditional gaps, improve access to care and educate patients? What incentives were paid to primary care doctors who went over and above the traditional “standard of care” to coordinate, monitor, and deliver care even during those critical periods of transitions? What about on patient outreach? Who is calling the member who hasn’t reached out to their PCP after enrolling? Or, are we only reaching out to those that are over-utilizing services?

Education is the only answer to a sustainable system.

What training is mandated for HCC Coders? Why aren’t physicians being taught the underlying principles of risk adjustment instead of being asked to assign specific ICD-9 codes to their MA members? Where is the transparency that Obamacare was intended to provide?

What if the answer to our healthcare crisis isn’t in the millions of medical records we are auditing and re-auditing? What if the answer isn’t in the “missing diagnosis” codes or the “monetary penalties such as recoupments”?

But, instead in the investment of education for patients, providers and office staff? What if the answer was creating more flexibility in the delivery of care or strengthening communities to bring that sense of responsibility into our neighborhoods? What if we took the money invested in prosecuting and defending waste, fraud and abuse and redirecting it into improving access and developing mobile platforms to meet the needs of patients?

Empirical Risk Management was able to create this personalized, comprehensive, integrated care in our recent pilot program. The cost of the program was less than $5 per member per month, and the value it created extended beyond quality measures and HEDIS - it instilled a desire to make better choices.

If we can innovate for as little as $5,per member per month, I can't help but wonder where the other $195 was spent?

Lincor Solutions Launches World’s First Mobile Solution for Patient Engagement and Clinical Services

MEDIVista MOBILE delivers services to Apple iPad and Android devices

DUBLIN -- 

Lincor announces the latest addition to the MEDIVista product suite – MEDIVista MOBILE, during eHealth Week in Dublin.

MEDIVista MOBILE delivers patient services to iPads and Android wireless tablets and is a modular extension to the proven MEDIVista service delivery platform already deployed in over 20 countries and 125 hospitals. MEDIVista provides patient centric content and applications to fixed bedside terminals, improving patient outcomes and workflow for both nurses and physicians.

“Many hospitals are facing demands to develop a BYOD (Bring your own Device) strategy so patients can use their own mobile devices,” explains Lincor Solutions co-founder and CTO Enda Murphy. “Without proper management and control, this can lead to strain on the hospital wireless infrastructure. The proven MEDIVista server technology gives hospitals this control plus the ability to fully manage a potentially lucrative revenue stream.”

Business Wire - MEDIVista MOBILE in use by a patient to access a range of services including live TV and Movies on Demand

Richard Cooke, Lincor Solutions CEO,continues, “The rise of tablet devices has led to an increased expectation from patients and their visitors that they can use their own devices while in hospital. MEDIVista MOBILE enables just that and is a world first solution for hospitals to deliver live TV, Movies on Demand, internet access and Skype to both fixed bedside terminals and mobile tablet devices through a centrally managed service. Customers new to MEDIVista also get the peace of mind that comes from having the solution underpinned by tried and tested technology designed for the hospital environment.”

About Lincor Solutions

Lincor Solutions, founded in 2003, operates internationally from corporate offices in Nashville, Tennessee, as well as Dublin and Cork, Ireland. With sales offices in Toronto, Canada, Bordeaux, France, and Vienna, Austria, the company supports the largest installed base of its type worldwide. Lincor’s MEDIVista product set is delivered through a network of channel and technology partners in Europe, Middle East, Asia and the Americas.

Lincor will be showcasing MEDIVista MOBILE at eHealth Week Booth #617

For more information, visit www.lincor.com