The Affordable Care Act-inspired effort to find more effective ways to serve the so-called dual eligible population – mostly the disabled and low-income elderly covered by both Medicare and Medicaid – is not providing the kind of results policy-makers expected when they initiated new efforts to serve this high-cost population.

But not all of the news is bad.

On one hand, enrollment figures for those eligible to participate have not met expectations, with some of those eligible afraid they might lose their providers and some of those providers persuading their patients not to participate. In addition, some health plans that participated in the earliest efforts have withdrawn in the face of declining enrollment.

On the other hand, employing care managers to serve members has shown signs of reducing hospitalizations and Medicare costs and individuals who do participate have expressed satisfaction with the service they are receiving.

For a closer look at the effort’s expectations, where it has succeeded, and where it has encountered challenges, see this Wall Street Journal article.…

Citing the growing consolidation of hospitals and physician practices and the higher rates Medicare pays for care delivered in hospital outpatient departments, the U.S. Government Accountability Office (GAO) has recommended that Congress

…consider directing the Secretary of the Department of Health and Human Services to equalize payment rates between settings for E/M [evaluation and management] office visits…

The recommendation comes after a GAO study that documented the increase in “vertical consolidation” between hospitals and physician practices in recent years and the increased costs for outpatient services this leads to for the Medicare program. The GAO report notes that “Such excess payments are inconsistent with Medicare’s role as an efficient purchaser of health care services.” It also notes that Medicare lacks the statutory authority to make such changes on its own.

For a closer look at this issue and why it is commanding the attention of the GAO and others, go here to see the GAO report Increasing Hospital-Physician Consolidation Highlights Need for Payment Reform.…

The Senate Finance Committee’s chronic care working group has issued a policy options document presenting more than 20 proposals for improving how Medicare serves beneficiaries with chronic medical conditions.

The document is the product of a bipartisan work group.   The proposals it presents include:

• Expanding the independence at home model of care
• Expanding access to home hemodialysis therapy
• Providing Medicare Advantage enrollees with hospice benefits
• Allowing end-stage renal disease beneficiaries to choose a Medicare Advantage plan
• Providing continued access to Medicare Advantage special needs plans for vulnerable populations
• Improving care management services for individuals with multiple chronic conditions
• Addressing the need for behavioral health among chronically ill beneficiaries
• Adapting benefits to meet the needs of chronically ill Medicare Advantage enrollees
• Expanding supplemental benefits to meet the needs of chronically ill Medicare Advantage enrollees
• Increasing convenience for Medicare Advantage enrollees through telehealth
• Providing ACOs the ability to expand use of telehealth
• Maintaining ACO flexibility to provide supplemental services
• Expanding use of telehealth for individuals with stroke
• Ensuring accurate payment for chronically ill individuals
• Providing flexibility for beneficiaries to be part of an accountable care organization
• Developing quality measures for chronic conditions
• Encouraging beneficiary use of chronic care management services
• Establishing a

The agency that advises Congress on Medicare payment issues has suggested to the Centers for Medicare & Medicaid Services (CMS) that it revise its star ratings systems for Medicare Advantage plans.

In a letter to CMS in response to its request for comment on star ratings, the Medicare Payment Advisory Commission (MedPAC) agreed with CMS that there is evidence of a difference in Medicare Advantage plan performance based on the low-income status or disability of plan members. While CMS continues to consider how to adjust for such a challenge, MedPAC recommended an interim approach called a “Categorical Adjustment Index” that would

… group MA contracts together, by deciles (for example), based on their share of the relevant populations (low-income, disabled). For each of these initial contract groupings, there would be a comparison between the overall or summary star rating determined under the current methodology, and an overall or summary star rating determined if there are adjustments made to measure results. The adjustment to the measure results would be based on a beneficiary-level regression model that determines the average within-contract difference in measure results for the relevant populations. The initial grouping of contracts would then be combined (if appropriate) into final …

Last week the commissioners serving on the Medicare Payment Advisory Commission (MedPAC) met in Washington, D.C. to discuss the group’s future recommendations to Congress.

While MedPAC’s recommendations are not binding on Congress or the administration, they are highly respected and often find themselves worked into new law or regulations.

Among the issues MedPAC addressed during two days of public meetings were:

• Medicare inpatient and outpatient payments
• the Medicare Advantage program star rating system
• payments to ambulatory surgery centers, skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals
• payments for physician services, home health services, hospice care, and outpatient dialysis

Find issue briefs on each subject, and copies of the presentations MedPAC staff made to commissioners, here on MedPAC’s web site.…