Archive for May, 2015


GAO Questions Medicare Physician Rate-Setting

Medicare needs to improve how it sets the rates it pays to physicians, according to a new report from the U.S. Government Accountability Office (GAO).

According to the report Medicare Physician Payment Rates: Better Data and Greater Transparency Could Improve Accuracy, Medicare relies too heavily on inadequate survey data and physician recommendations on how they should be paid.

To address this problem, the GAO recommends that Medicare do a better job of documenting its rate-setting process, rely more on improved data rather than physician recommendations when setting rates, and introduce greater transparency in its rate-setting efforts.

Find links to a summary of the GAO report and the report itself here.…

Feds Propose New Medicaid Managed Care Regs

The Centers for Medicare & Medicaid Services (CMS) has proposed its first major changes in regulations governing Medicaid managed care in more than a decade.

In a 653-page draft regulation published on Monday, CMS proposes imposing a medical-loss ratio on Medicaid managed care plans; establishing new standards for adequate provider networks; partially lifting the ban on payments to institutions for mental diseases; pursuing greater transparency in rate-setting; and new quality initiatives that mirror those of Medicare and the federal marketplace.

In addition, the proposed regulation calls for new marketing guidelines for Medicaid managed care plans, improved access to information for Medicaid beneficiaries, and new program integrity measures. It also proposes better aligning the governance of CHIP with Medicaid, new requirements for managed long-term services and supports, and new tools for fostering delivery system reform at the state level.

Interested parties have until July 27 to submit comments to CMS about the proposals.

To learn more about this major regulatory proposal, see this Kaiser Health News article; find the regulation here; and see this CMS fact sheet on the draft regulation.


GAO Reports on Services for the Elderly

With many older Americans hoping to age in their homes and communities, their ability to do so often depends on the available of home- and community-based services and supports. The Older Americans Act of 1965 requires the U.S. Administration on Aging to coordinate and promote such a system of services.

The U.S. Government Accountability Office (GAO) recently took a look at this process: how the Administration on Aging coordinates and funds such efforts, how services are planned at the local level, and how local and federal efforts are coordinated.

In its new report Federal Strategy Needed to Help Ensure Efficient and Effective Delivery of Home and Community-Based Services and Supports, the GAO found that different places went about these tasks in different ways and that the Administration on Aging must compete within the U.S. Department of Health and Human Services for resources. It recommends that the Department of Health and Human Services do more to “facilitate development of a cross agency federal strategy to ensure efficient and effective use of federal resources” for home- and community-based services. The department agreed with this recommendation.

Find the GAO report here.


Underinsurance Remains a Problem

Twenty-three percent of American adults are uninsured, according to a new survey by the Commonwealth Fund.

Among them, 14 million had deductibles that exceeded five percent of their income while another 24 million had deductibles that fell below that threshold but had out-of-pocket health care costs – deductibles, co-insurance, co-payments, and out-of-network payments – that exceeded ten percent of their income.

The figures are for 2012 and reflected no change since 2010 but were nearly twice those found in 2003.

In addition, the survey found that the proportion of the insured with high-deductible plans has more than tripled, from three percent to 11 percent, since 2003. This is believed to reflect the proliferation of high-deductible plans in recent years – a proliferation that has increased with implementation of the Affordable Care Act and the many high-deductible plans offered through the federal exchange and state exchanges. This survey, however, did not distinguish between pre- and post-Affordable Care Act insurance policies.

For a closer look at the numbers, who is underinsured, the role of high-deductible plans in being underinsured, the effect of being underinsured on gaining access to care and addressing health problems, and more, see The Problem of Underinsurance and How

Hospitals Address Quality With Quantity Standards

On the heels of an analysis that found that patients who undergo surgery at hospitals at which such surgeries are not performed frequently are more likely to die or suffer complications, some hospitals have decided to establish minimum-volume standards for both surgeons and types of procedures.

A recent report in U.S. News & World Report found that when patients undergo surgical procedures by doctors who do not perform those procedures often or have procedures performed at hospitals at which those procedures are not performed frequently, they have a greater chance of suffering complications from surgery, unsatisfactory outcomes, or even dying than those served by better-prepared surgeons and hospitals.

Based in part on these findings, several large academic medical centers have announced that they will establish minimum-volume standards for selected surgical procedures, such as knee and hip replacements and bypass surgery without repair or replacement.

For a closer look at U.S. News & World Report’s findings, go here. To learn about how several academic medical centers are responding to this challenge, go here.