Archive for January, 2016


Challenges In Determining Effectiveness of Dual-Eligible Programs

The federal government is encountering challenges in evaluating the effectiveness of programs designed to serve low-income elderly patients served by both Medicare and Medicaid – patients known as dual-eligibles.

Or so concludes the U.S. Government Accountability Office in a new report.

With the dually eligible accounting for 35 percent of total Medicare and Medicaid expenditures, the Centers for Medicare & Medicaid Services’ “Financial Alignment Initiative” has worked to find new and better ways to care for such individuals. Such efforts have been plagued, however, by challenges in locating such individuals at times because they are often part of a transient population. In addition, the GAO review, which examined programs in the first five states to launch such initiatives – California, Illinois, Massachusetts, Virginia, and Washington – found that the data reported by the individual states often differed, making it difficult to compare both different approaches to serving the dual-eligible population and overall program results.

The GAO has recommended that CMS develop new comparable data measures and better align the program’s existing methodologies.

To learn more about early experiments in serving the dual-eligible population, go here to see the GAO report Medicare and Medicaid: Additional Oversight Needed of CMS’s Demonstration to

Nursing Home Penalties Up in Pennsylvania

State actions against nursing homes increased significantly in Pennsylvania in 2015, according to a published news report.

There were more such actions – 52 fines and licensing actions in 2015 – than in any year since 2009.

State officials attribute the increase to growing awareness of such problems in the wake of a July 2015 lawsuit against the state over nursing home abuses and an increase in public complaints after the state eliminated a 2012 requirement that those lodging such complaints identify themselves when doing so.

For a closer look at why enforcement efforts appear to be on the rise and the conditions that have led to closer scrutiny of nursing homes in the state, see this Pittsburgh Post-Gazette article.…

Report on Social Risk Factors in Medicare Payments

As Medicare continues to move toward making provider payments based on patient outcomes rather than services provided, the National Academies of Sciences, Engineering, and Medicine has issued a new report on the potential impact of socio-economic factors on those patient outcomes.

The report, commissioned by the U.S. Department of Health and Human Services, is based on a literature search and identifies five socio-economic risk factors that could affect Medicare patient outcomes and quality measures: socio-economic status; race, ethnicity, and cultural context; gender; social relationships; and residential and community context. HHS asked the Academies to look into this issue because of the growing perception that Medicare payment policies may be unfair to providers that care for especially large numbers of socio-economically disadvantaged Medicare patients.

The report, Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors (2016), is the first of an expected five Academies reports on the subject. The second report will identify best practices in serving socio-economically disadvantaged communities; the third will seek to identify factors that are and are not within providers’ control; the fourth will present recommendations; and the fifth, expected in 2019, will summarize the first four.

Find the National Academies of Sciences, …

Governors Seek Better Medicaid Data

In response to a request from the Senate Finance Committee on Medicaid data reporting, the nation’s governors have called for access to better Medicaid data and streamlined federal data reporting requirements.

In a letter to the committee’s leadership, the National Governors Association wrote that

NGA shares your interest in improving the quality and accessibility of Medicaid data, both for traditional program integrity purposes and for transforming the health care system to provide higher-quality, more efficient care. Like you, governors are seeking timely, accurate data to inform policymaking and better understand how their programs are performing. Governors also are working hard to ensure providers have the information needed to improve outcomes for their patients.

Governors also indicated that they would like access to more Medicare data so they can better serve the dually eligible.

In addition, they requested that data demands be limited to reporting that helps pursue specific policy objectives; more streamlined reporting on section 1115 Medicaid waivers; and a more strategic approach to quality reporting.

Find the NGA letter to Senate Finance Committee leadership here, on the NGA web site.…

New Medicaid Enrollees Cost Less to Serve

Contrary to fears that the long-time uninsured who became eligible for Medicaid under Affordable Care Act eligibility expansion would turn to providers with a long litany of expensive-to-treat medical problems, preliminary data suggests that such individuals are actually less costly to treat than the average Medicaid recipient.

Preliminary data released by the Centers for Medicare & Medicaid Services based on claims data from the first quarter of 2014 – the first time period after Medicaid expansion began in some states – found that the average new adult Medicaid enrollee cost $4513 to serve, as opposed to the $7150 it cost to serve Medicaid beneficiaries across all groups.

The Kaiser Family Foundation has done a great deal of analysis of early data under Medicaid expansion, looking at costs per beneficiary, geographic data, Medicaid expansion states, enrolment changes, and more. Find its extensive analyses here in the report “Medicaid Expansion Spending and Enrollment in Context: An Early Look at CMS Claims Data for 2014.”…