Monday, November 25, 2013

On December 17, 2013, CMS is hosting a call to provide an overview of the quality reporting provisions in the 2014 Physician Fee Schedule (PFS) final rule

On December 17, 2013, CMS is hosting a call to provide an overview of the quality reporting provisions in the 2014 Physician Fee Schedule (PFS) final rule (which has not yet been released). The call will provide details on how an eligible professional or group practice can meet the criteria for satisfactory reporting for the 2014 Physician Quality Reporting System (PQRS) incentive and 2016 PQRS payment adjustment (including a discussion of criteria for satisfactory participation under the new qualified clinical data registry option). The call also will provide updates on the Electronic Health Record (EHR) Incentive Program and Physician Compare.

OIG STRATEGIC PLAN 2014‒2018 : Driving Positive Change

 Goals, Priorities, and Strategies

OIG’s goals and priorities reflect the positive changes toward which we strive. Accompanying each priority listed below are illustrative strategies and indicators, as well as examples of OIG’s work to improve HHS programs and ensure the health and safety of the people served by them.

Goal One: Fight Fraud, Waste, and Abuse

Critical to OIG’s mission is fighting fraud, waste, and abuse. We will continue to employ a multi-faceted approach of prevention, detection, and deterrence.

Priority: Identify, investigate, and take action when needed

Strategy. OIG uses data analysis and risk assessments of emerging issues to identify suspected fraud, waste, and abuse and deploy our oversight and enforcement resources. Our investigations result in criminal convictions and penalties, civil settlements, and administrative actions against those who commit fraud. Updates on OIG’s enforcement actions are available on our website. Looking ahead, we will build on successful enforcement models such as the Medicare Fraud Strike Force teams to enhance our enforcement results in other HHS programs. Key focus areas include: Medicare and Medicaid program integrity and waste in HHS programs. We will also continue implementing and refining protocols for self-disclosure of wrongdoing.

Priority: Hold wrongdoers accountable and maximize recovery of public funds

Strategy. OIG partners with the Department of Justice (DOJ) and HHS on Medicare Fraud Strike Force teams and other health care fraud enforcement activities through the Health Care Fraud and Abuse Control (HCFAC) program. On average, the HCFAC program recovers more than $7 for every $1 invested and protects programs through nonmonetary results, such as criminal convictions and exclusions of providers from participation in Federal health care programs. The latest HCFAC results are available in the annual HCFAC Report to Congress. We will continue to pursue all appropriate means to hold fraud perpetrators accountable and to recover stolen or misspent HHS funds. Key focus areas include: identifying and recovering improper payments and utilizing exclusions and referrals for debarment to protect HHS programs and beneficiaries.

Priority: Prevent and deter fraud, waste, and abuse

Strategy. OIG identifies fraud, waste, and abuse vulnerabilities in HHS programs and operations and advises HHS program administrators and policymakers on how tomplement effective safeguards. For example, our recommendations for strengthening HHS program administration and grants management and our grant fraud prevention training for HHS are summarized on our website. We also educate health care providers and provide them tools to help prevent fraud and abuse; these tools are available on our website. Looking ahead, we will apply the lessons we have learned about fraud vulnerabilities and effective prevention to HHS’s new and evolving programs. Key focus areas include: promoting compliance with Federal requirements and resolving noncompliance; advising HHS on key safeguards to prevent fraud, waste, and abuse, and assessing whether providers and suppliers, grantees, and others are qualified to participate in Government programs.

Goal Two: Promote Quality, Safety, and Value

HHS programs touch the lives of all Americans. OIG is committed to promoting quality of care and public safety in those programs and maximizing the value of Federal dollars invested.

Priority: Foster high quality of care

Strategy. OIG will continue to evaluate and recommend improvements to the systems intended to promote quality of care, exemplified by our series of reviews of adverse events (patient harm resulting from medical care), available on our website. We will also investigate and refer for prosecution cases involving abuse or grossly deficient care of Medicare or Medicaid patients. Looking ahead, OIG plans to expand our portfolio of work on quality of care. Key focus areas include: promoting quality of care in nursing facilities and home- and community-based settings, access to and use of preventive care, and quality improvement programs.

Priority: Promote public safety

Strategy. OIG recommends improvements to HHS programs to ensure adequate emergency preparedness and response; to protect the safety of food, drugs, and medical devices (summarized on our website); and to ensure that their grantees (e.g., Head Start and child care providers) meet safety standards. OIG will continue to prioritize fraud investigations that have public safety as well as financial implications and to look for comprehensive solutions. For example, we will continue to investigate prescription drug fraud cases and plan to work with leadership across HHS operating divisions to identify systemic solutions for this problem.

Priority: Maximize value by improving efficiency and effectiveness

Strategy. OIG’s findings and recommendations promote efficiency and effectiveness in specific programs and across HHS. We also work to ensure that HHS programs do not overpay for services or products relative to their value in the marketplace―for examples, see our “Spotlight on Bad Bargains.” Looking ahead, OIG also plans to assess programs intended to achieve value through care coordination and new ways of delivering and paying for care, as well as the reliability and integrity of quality, outcomes, and performance data.

Goal Three: Secure the Future

OIG will continue to address program and operational vulnerabilities that affect the long-term health and viability of HHS programs.

Priority: Foster sound financial stewardship and reduction of improper payments

Strategy. OIG reviews HHS’s annual financial statement audits and error rate reports. We also conduct targeted reviews to identify improper payments to be recovered and recommend management improvements to systemic weaknesses that contribute to improper payments. For example, our series of hospital audits (available on our website) identified common billing and payment errors and recommended fixes and recoveries of funds that were overbilled to the Government (overpayments). Looking ahead, OIG will continue to prioritize work on billing and payment errors by providers, effective program administration and contract oversight, and inefficiencies that result in wasteful spending.

Priority: Support a high-performing health care system

Strategy. OIG is working to support a high-performing health care system to foster better health outcomes and lower costs. OIG’s efforts include promoting quality, coordination, and efficiency. We provide technical assistance on safeguards to protect new and changing systems and programs from fraud, waste, and abuse. As HHS manages the transition to payments based on value rather than volume, we plan to conduct reviews and recommend changes to maximize overall value, protect program integrity, and foster value and high performance.

Priority: Promote the secure and effective use of data and technology

Strategy. Data and technology promise to drive improvements in health care and human services at lower costs. OIG will continue to advise program administrators and policymakers on promoting the secure and effective use of data and technology. OIG’s work in this area is summarized on our website. Looking ahead, key focus areas include: the accuracy and completeness of program data (e.g., Medicaid data), the privacy and security of personally identifiable information, and the security and integrity of electronic health records.

Goal Four: Advance Excellence and Innovation

OIG strives to advance excellence and innovation in our own organization and operations.

Priority: Recruit, retain, and empower a diverse workforce

Strategy. OIG achieves its mission through its workforce. To identify, understand, and address the challenges facing HHS, we will continue to invest in our workforce by recruiting and retaining talented employees and by maintaining workforce excellence and the highest standards of professional conduct. We will foster a work environment that enhances productivity, innovation, excellence, and employee satisfaction and will cultivate a culture of continuous improvement. More information about careers at OIG is available on our website.

Priority: Leverage leading-edge tools and technology

Strategy. OIG maximizes the returns on our investments by leveraging data analytics and technology to inform our decisions about where to best direct our resources. For example, analysis of Medicare billing patterns has guided our decisions about where to deploy Medicare Fraud Strike Force teams and data analysis helps us to uncover fraud and conspiracies in specific cases, such as those highlighted in our Semiannual Report to Congress. Looking ahead, we will continue to use the best data, analytic tools, and technologies available to maximize the impact of our work.

Priority: Promote leadership, vision, and expertise

Strategy. In an evolving health and human services landscape, OIG focuses on building leadership and expertise to drive positive change. Our multidisciplinary approach affords us a range of tools to develop sound and innovative solutions. More information about OIG’s multidisciplinary workforce is available on our website. As HHS programs, technology, and the environment change, embracing innovation will help us maintain relevance and achieve impact.

The entire report in PDF:

Google creates Helpouts, a HIPAA compliant video platform that can be used by Physicians & Patients

Post image for Google creates Helpouts, a HIPAA compliant video platform that can be used by Physicians & Patients
Google Helpouts is a new video service by Google that connects individuals seeking help with experts via real time online video. Healthcare providers are using the platform to connect with Patients. Helpouts is built on top of Google’s Hangouts platform and is HIPAA compliant.
Google says it was created to provide “real help from real people in real time.” People who offer help through the service are calledproviders and can be businesses as well as individuals. Providers must pass a screening process in order to qualify as Helpouts providers.
Once approved, providers create and maintain listings that explain their offerings, qualifications, prices and schedules. Payments are made through Google Wallet and pricing is based either per minute, per session, or free. While Google charges 20% of the fees, health-related providers are not yet being charged. Helpouts Providers can be rated at the end of a session by the user.
Google Helpouts’ health providers include those helping with mental health counseling, speech impediments, carpal tunnel and breastfeeding. One Medical Group, a concierge medical practice, is also a provider. Google Ventures led a $30 million funding round for One Medical Group in March earlier this year. One Medical recommends the service to be used for those with colds, allergies, sinus issues, simple infections, UTI’s, rashes and general advice and consultation.
So far Helpouts is limited to about 1000 providers, but Google is accepting requests for invitation.

Medicare Advantage Fact Sheet | The Henry J. Kaiser Family Foundation

Medicare Advantage Fact Sheet | The Henry J. Kaiser Family Foundation

Medicare Advantage Fact Sheet

Since the 1970s, Medicare beneficiaries have had the option to receive their Medicare benefits through private health plans, mainly health maintenance organizations (HMOs), as an alternative to the federally administered traditional Medicare program.  The Balanced Budget Act (BBA) of 1997 named Medicare’s managed care program “Medicare+Choice” and the Medicare Modernization Act (MMA) of 2003 renamed it “Medicare Advantage.”  Medicare payments to plans are projected to total $154 billion in 2014, accounting for 26% of total Medicare spending (CBO May 2013 Medicare Baseline).
Over the past decades, Medicare payment policy for plans has shifted from one that produced savings to one that focused more on expanding access to private plans and providing extra benefits to Medicare private plan enrollees.  These policy changes resulted in Medicare paying private plans more per enrollee than the cost of care for beneficiaries in traditional Medicare, on average (MedPAC 2010). The Affordable Care Act (ACA) of 2010 produced another shift in payment policy by reducing federal payments to Medicare Advantage plans over time, bringing them closer to the average costs of care under the traditional Medicare program. It also provided for new bonus payments to plans based on quality ratings, beginning in 2012, and required plans beginning in 2014 to maintain a medical loss ratio of at least 85%, restricting the share of premiums that Medicare Advantage plans can use for administrative expenses and profits.

Medicare Advantage Enrollment

In 2013, the majority of the 52 million people on Medicare are in the traditional Medicare program, with 28% enrolled in a Medicare Advantage plan (Exhibit 1).  Since 2004, the number of beneficiaries enrolled in private plans has almost tripled from 5.3 million to 14.4 million in 2013.
Exhibit 1. Total Medicare Private Health Plan Enrollment, 1999-2013
Exhibit 1. Total Medicare Private Health Plan Enrollment, 1999-2013
Medicare Advantage enrollment rates vary by state, ranging from 49% in Minnesota to less than 1% in Alaska, and vary within states, by county (Exhibit 2).
Exhibit 2.  Share of Medicare Beneficiaries Enrolled in Medicare Advantage Plans, by State, 2013
Exhibit 2. Share of Medicare Beneficiaries Enrolled in Medicare Advantage Plans, by State, 2013

Medicare Advantage Plan Types

Medicare contracts with insurers to offer the following different types of health plans:
Local HMOs and PPOs contract with provider networks to deliver Medicare benefits.  HMOs account for the majority (65%) of total Medicare Advantage enrollment in 2013; local PPOs, account for 22% of all Medicare Advantage enrollees.
Regional PPOs were established to provide rural beneficiaries greater access to Medicare Advantage plans, and cover entire statewide or multi-state regions.  Regional PPOs account for 7% of all Medicare Advantage enrollees in 2013.
Private Fee-for-Service plans (PFFS), as authorized in 1997, were not required to establish networks, but since 2011, have generally been required to do so. PFFS enrollment increased ten-fold from 0.2 million enrollees in 2005 to 2.2 million 2009, but has since declined to 0.4 million enrollees in 2013, or 3% of all Medicare Advantage enrollees.
Other types of private plans (e.g., cost plans, HCPP, PACE plans, medical savings accounts, demonstrations and pilots) account for 3% of Medicare Advantage enrollment.
Special Needs Plans (SNPs), typically HMOs, are restricted to beneficiaries who: (1) are dually eligible for Medicare and Medicaid; (2) live in long-term care institutions (or would otherwise require an institutional level of care); or (3) have certain chronic conditions.  Since 2006, the number of SNP enrollees has increased from 0.5 million to 1.6 million enrollees in 2013; enrollment in SNPs for dual eligibles accounts for 82% of total enrollment in SNPs.

Payments To Medicare Private Plans

Medicare pays Medicare Advantage plans a capitated (per enrollee) amount to provide all Part A and B benefits.  In addition, Medicare makes a separate payment to plans for providing prescription drug benefits under Medicare Part D.  Prior to the BBA of 1997, Medicare paid plans 95% of average traditional Medicare costs in each county because HMOs were thought to be able to provide care more efficiently than could be provided in traditional Medicare.  These payments were not adjusted for health status, and HMOs typically enrolled beneficiaries who were healthier than average.
Beginning in the late 1990s, Congress revised the payment formula to attract more plans throughout the country, particularly in rural and certain urban areas. The BBA of 1997 established a payment floor, applicable almost exclusively to rural counties.  The Benefits Improvement and Protection Act (BIPA) of 2000 created payment floors for urban areas and increased the floor for rural areas.  The MMA of 2003 increased payments across all areas.
Since 2006, Medicare has paid plans under a bidding process.  Plans submit “bids” based on estimated costs per enrollee for services covered under Medicare Parts A and B; all bids that meet the necessary requirements are accepted.  The bids are compared to benchmark amounts that are set by a formula established in statute and vary by county (or region in the case of regional PPOs).  The benchmarks are the maximum amount Medicare will pay a plan in a given area. If a plan’s bid is higher than the benchmark, enrollees pay the difference between the benchmark and the bid in the form of a monthly premium, in addition to the Medicare Part B premium.  If the bid is lower than the benchmark, the plan and Medicare split the difference between the bid and the benchmark; the plan’s share is known as a “rebate,” which must be used to provide supplemental benefits to enrollees.  Medicare payments to plans are then adjusted based on enrollees’ risk profiles.
The ACA of 2010 revised the methodology for paying plans and reduced the benchmarks. For 2011, benchmarks were frozen at 2010 levels.  Reductions in benchmarks will be phased-in over 2 to 6 years between 2012 and 2016.  By 2017, when the new benchmarks are fully phased-in, the benchmarks will range from 95% of traditional Medicare costs in the top quartile of counties with relatively high per capita Medicare costs (e.g., Miami-Dade), to 115% of traditional Medicare costs in the bottom quartile of counties with relatively low Medicare costs (e.g., Boise).
Quality-based Bonus Payments.  The ACA specified that plans with higher quality ratings would receive bonus payments added to their benchmarks, beginning in 2012.  The ACA also reduced rebates for all plans, but allowed plans with higher quality ratings to keep a larger share of the rebate than plans with lower quality ratings.  A CMS demonstration was implemented in 2012 that superseded bonuses specified by the ACA, raised the size of the bonus payments, and increased the number of plans that would receive bonus payments, providing an additional $8 billion in bonuses between 2012 and 2014.

Supplemental And Prescription Drug Benefits

Medicare Advantage plans are paid to provide all Medicare benefits.  In addition, if they receive rebates, they are required to use these payments to provide additional benefits, such as eyeglasses, or reduce premiums or cost sharing for covered benefits.  Medicare Advantage plans are generally required to offer at least one plan that covers the Part D drug benefit.  In 2014, 83% of Medicare Advantage plans offer prescription drug coverage, and 50% provide some coverage in the gap (Kaiser Family Foundation, Nov. 2013).  All Part D enrollees receive a 50% discount on brand-name drugs in the gap, beginning in 2011.  Since 2011, all plans have been required to limit beneficiaries’ out-of-pocket spending to no more than $6,700.

Medicare Advantage Premiums

The average premium for enrollees of Medicare Advantage Prescription Drug plans will be $39 per month in 2014, weighted by 2032 enrollment, if enrollees remain in the same plan. This reflects a 14% increase in premiums from 2013.  Premiums were lower for HMOs and regional PPOs than for local PPOs and PFFS plans; we do not know whether cost sharing for individual services has changed and thus do not know to what extent enrollees’ out-of-pocket expenses have changed (Exhibit 3).
Exhibit 3.  Weighted Average Monthly Premiums for Medicare Advantage Prescription Drug Plans, Total and by Plan Type, 2013-2014
Exhibit 3. Weighted Average Monthly Premiums for Medicare Advantage Prescription Drug Plans, Total and by Plan Type, 2013-2014

Future Issues

Historically, Congress has enacted a number of changes that affect the role of private plans under Medicare, including adding new types of plans to the program, increasing or decreasing Medicare payments to plans, tightening the rules governing the marketing of the plans, and even changing the name of the program (from “Medicare+Choice” to “Medicare Advantage”).  The Affordable Care Act of 2010 made a number of changes to the Medicare Advantage program, driven largely by concerns about the payment system and its effect on Medicare spending.
In 2014, Medicare Advantage markets and plans will look much as they did  in 2013, in terms of the number of plans available to beneficiaries, although premiums and out-of-pocket limits are projected to rise for current enrollees who do not change plans.  Over the longer term, companies offering Medicare Advantage plans may respond to payment changes in several different ways, depending on the circumstances of the company, the location of their plans, their historical commitment to the Medicare market, their ability to leverage efficiencies in the delivery of care to enrollees, and possibly their quality ratings and bonus payments.  Decisions made by these firms could have important implications for beneficiaries with respect to their choice of plans, out-of-pocket costs, and access to providers.
Achieving a reasonable balance among multiple goals for the Medicare program—including keeping Medicare fiscally strong, setting adequate payments to private plans, and meeting beneficiaries’ health care needs—will continue to be a critical issue for policymakers in the future.