Posts Tagged ‘Center for Medicare and Medicaid Services’

Federal Government Bets $2 Billion on Oregon Medicaid Program

Thursday, June 14th, 2012

Oregon Governor John Kitzhaber, a former emergency room physician, has convinced the Center for Medicare and Medicaid Services (CMS) that he can significantly improve Medicaid treatment and do it cheaper by altering the way the sickest people in his state get healthcare.  If Kitzhaber’s experiment works, it could have repercussions for the entire nation.  According to Kaiser Health News, Oregon’s major cities — Portland, Salem and Eugene — will have their own umbrella groups for treating the Medicaid population, in effect, a “coordinated care organization.” (CCOs)  Under these umbrellas will be a majority of the heavy hitters in the health sector including hospitals, doctors, mental health providers and dentists.

Kitzhaber wants to switch Oregon’s 600,000 Medicaid patients into CCOs, which will accept a flat fee for delivering each patient’s care while remaining within that budget, with bonuses for quality metrics.  If patient care costs more than the flat fee, healthcare providers must eat the difference.

Kitzhaber’s idea is that healthcare businesses will stop competing for patients and instead link to each other electronically so that it’s easier for providers to share information.  Patients can see whichever provider they need to get maximal care.  The sickest people will have a $20-an-hour outreach worker to assist them in navigating the system and avoiding pricey hospitalizations.  Each outreach worker will manage a caseload of approximately 30 patients – with the goal of saving Medicaid hundreds of thousands of dollars.

I think this is really a defining moment for health care in the State of Oregon and, I think that if we’re successful, probably for healthcare beyond our borders,” Kitzhaber said.  The plan is supported by both Republicans and Democrats, with the state’s leaders putting their political reputations on the line for this deal.  The legislature passed its entire budget in the belief that the federal government was going to fund the program.  Unions and businesses in Oregon also support the program.  Malia Wasson, the president of US Bank in Oregon, celebrated the news.  “Governor, I know that you’re not prone to being overly demonstrative,” she said.  “But would you indulge me with a high five?”

Naturally, there are skeptics.  State Representative Jim Weidner voted against the Medicaid bill.  “It doesn’t really drive down the cost of healthcare.  It’s just shifting costs into different spots,” Weidner said.  He believes that the program ultimately will cost the state money.  Kitzhaber disagrees, noting that the coordinated care organization will be paid with a lump sum to manage Medicaid patients.

Under Oregon’s present system, hospitals and doctors don’t have a financial incentive to make people better.  To the contrary, if a patient keeps coming back, the provider keeps getting paid.  Under the new system, the faster a patient recovers, the coordinated care organization can keep more money.  Kitzhaber believes that over the next five years, Oregon will be able to save Medicaid every cent of the $2 billion the state’s been promised.

“We estimated that if every state Medicaid program in the country were to adopt this model, the net savings would be about $1.5 trillion dollars over 10 years,” Kitzhaber said.  Congress is looking at $1.2 trillion in cuts over the next 10 years after the super committee failed to come up with budget cuts.  Despite the fact that Oregon is pleased with itself, the federal government has said that if the state doesn’t show cuts to Medicaid spending by two percent next year, the new money could dry up.

Oregon is the only state to attempt to rethink Medicaid backed by federal tax dollars, said Dr. Roger Stark, a physician and healthcare policy analyst with the Washington Policy Center.  “The Oregon program is based on an HMO model which ties into quality controls to hold costs down.  But Oregon is broke, and they didn’t have the seed money to start the program because like all the states, they’re broke.  Oregon really stood on its head, and the CMS gave in.  Oregon’s program lines up with President Barack Obama’s law, and they probably sold it to the administration as a sort of pilot program,” Stark said.

According to Stark, the CCO approach resembles the HMO model, which was reviled by doctors and patients.  “The physicians hated it because they couldn’t control treatment decisions and had to focus on cutting costs, and the patients hated it because they couldn’t get complete treatment — they had no trouble seeing a primary care physician, but it was extremely difficult seeing a specialist,” Stark said, noting that rationing is inevitable under this approach.  “Oregon told CMS they could save money, which is pie in the sky.  Instead, there will be some form of rationing because they’re dealing with a fixed amount of money.  The rationing will be subtle and insidious.  Say you’re 60 years old and need a hip or knee replacement; they will tell that patient, ‘Oh, you don’t need that operation.’  Or they will tell him, ‘Take these pills, not those,’” Stark said.

Time to Resolve the “Doc Fix”

Wednesday, December 21st, 2011

Congress’ end of year to-do list inevitably includes the “doc fix” – billions of dollars to avoid deep rate cuts for physicians who treat Medicare’s 48 million patients.  Congressmen and Senators always defer the cuts demanded by a 1997 reimbursement formula — known as the sustainable growth rate (SGR) and which most believe needs to be entirely rewritten.  The deferrals are temporary, and the doc fix has become increasingly difficult to pass through a divided and deficit-wary Congress.  In 2010, Congress put off scheduled cuts five times, with the longest delay lasting one year.

The story is the same heading into 2012.  If lawmakers are unable to agree before returning home for the holidays, 500,000 physicians will face a stiff 27 percent cut beginning January 1.  Although Congressional leaders have vowed to prevent that, they disagree over how to pay for the fix.  There is little doubt some agreement will be reached, but that deal could be delayed until early next year.

The cost of congressional intervention, not surprisingly, has grown: Delaying the cuts — the solution Congress has chosen since 2003 — will cost $21 billion for a one-year delay and $38.6 billion for two years.  Repealing the formula would add approximately $300 billion to the deficit, according to the Congressional Budget Office.

No one imagined that the SGR would cause so much trouble when it was passed as a minor element of the Balanced Budget Act of 1997.  Nearly 15 years ago, Medicare physician spending, which accounts for a small share of the program’s overall outlay, was growing slowly.  The law included other restraints that have since been repealed.  Analysts predicted that, at most, the SGR formula would curb physician payments minimally.  “It wasn’t viewed as a big deal at the time,” said Paul Van de Water, an economist specializing in Medicare with the research group Center on Budget and Policy Priorities.  “They needed a few more billion dollars in savings (for the Balanced Budget Act), so they just tacked on the SGR arrangement.”

Kaiser Health News wonders why Congress doesn’t just scrap the SGR formula.  “Money is the biggest problem.  It would cost about $300 billion to stop the doc fix cuts over the next decade and Congress can’t agree on where to find that kind of cash.  Some lawmakers, including Senator Jon Kyl (R-AZ), have proposed using money saved from winding down the wars in Iraq and Afghanistan to finance a permanent fix.  While the idea has found favor among some Democrats, other Republicans oppose it.  For physicians, the prospect of facing big payment cuts is a source of mounting frustration.  Some say the uncertainty led them to quit the program, while others are threatening to do so.  Still, defections have not been significant to date, according to MedPAC.  Physician groups continue to lobby Congress to enact a permanent payment fix.”

Dr. Florence C. Barnett recently decided to quit seeing Medicare patients.  She said the plan covered approximately 33 percent of what it cost her to see patients — and found herself facing a growing Medicare patient population after other local neurosurgeons left the program in 2010.  “This is the way the government will ration healthcare,” Barnett said.  “The people who can afford it will have healthcare, and the people who are only on government support — they will not be able to find a doctor or they will have a very long wait.  It’s happening now.”

A survey conducted by the Medicare Payment Advisory Commission found that among patients looking for a new primary-care physician in 2010, 79 percent experienced no problems finding one.  According to the American Medical Association (AMA), which generally resists limits in reimbursements, nearly 33 percent of primary-care physicians already restrict how many Medicare patients they accept in their practices.

Physicians are once again relying on Congress to put off the impending cut.  It’s a scenario that Glen Stream, M.D. and president of the American Academy of Family Physicians, calls a “Lucy and Charlie Brown and the football thing.”  In other words, physicians have become numb to the whole situation.  This year, that numbness could be risky.  “Doctors are sort of numb from this,” Stream said.  “It’s concerning because I think there’s a very serious chance that this cut could go into place and yet many practicing physicians have heard this years and years in a row and it always seems to get averted at the last minute.  I think that they may not understand the gravity of the situation this time.”

Writing on the MDNews.com website, Maggie Behringer says that “Last year the battle to fund the Medicare deficit — $19 billion for the fiscal year — ended in a one-year measure.  The summer saw a hands-off stance from the Center for Medicare and Medicaid Services when the administration instructed providers to temporarily cease filing claims until Congress resolved a standstill over stimulus spending and unemployment benefits.  The cut projected for January, 2012, should Congress fail to enact the customary doc-fix, totals to 27.4 percent.  The core conflict for legislators — 19 of whom are physicians, themselves — emerges in the inability of the SGR to adapt in today’s economic environment.  The formula was originally developed to bind spending to the economy’s growth.  Despite initial success, the exponential climb in healthcare costs quickly surpassed the overall market.  The subsequent deficits to fund Medicare were further compounded by the recent depression and ongoing recession.  Even if Congress is able to act in time with a temporary doc-fix over the holidays, the fundamental dilemma will remain a question of funding just as the patient population eligible for Medicare benefits enters a major boom.”

Medicare Part D Costs Expected to Fall in 2012

Monday, August 22nd, 2011

Medicare Increased competition between Medicare Part D plans, greater generic drug use and more transparency for consumers are why the Center for Medicare and Medicaid Services (CMS) expects lower Medicare prescription drug premiums next year.  Next year, the average Medicare prescription drug plan premium will cost approximately $30, compared with an average of $30.76 in 2011, according to the Department of Health and Human Services (HHS).  CMS Administrator Dr. Donald Berwick said that the average premium is about 44 percent lower than what was estimated in 2003.

The Part D drug benefit,  enacted when George W. Bush was president, lets seniors and others on Medicare sign up for a privately administered, government-subsidized health plan to purchase their prescriptions.  The program enjoys high popularity with beneficiaries and has proven to be far less costly than budget analysts originally expected, partly because of competition among private plans and the growing use of less costly generic drugs.

HHS also announced that nearly 900,000 Americans in the Medicare Part D “doughnut hole” have benefited from a 50 percent discount in brand-name drugs in 2012.  HHS estimates that out-of-pocket savings on drug costs for Medicare beneficiaries to be about $461 million from January through June of this year.  The Obama administration has worked to strengthen the Medicare drug benefit with the help of the Patient Protection and Affordable Care Act (ACA).  The law phases out the coverage gap, long seen as one of the program’s weaknesses.  Last year, approximately four million seniors received $250 rebates because they fell into the gap in coverage.  This year, the law will provide 50 percent discounts on prescriptions for those who hit the doughnut hole.

Seniors can chose from a variety of Part D plans,  and Dr. Donald Berwick, administrator of the Center for Medicare and Medicaid Services, said competition “clearly helps” keep premiums from rising.  At the same time, he warned against overextending Part D.  HHS said 17 million seniors have received at least one preventive healthcare service without a co-pay.  The ACA eliminated co-pays for many preventive services under Medicare and will ultimately do the same for private insurance.

“This decline in the average creates more risk for plans like ‘Humana’ and ‘United Health’ that have a significant portion of the Part D members,” said Peter Costa, a Wells Fargo analyst.  Costa said one reason for the lower bids could be last year’s joint venture between Humana and Wal-Mart stores to offer Medicare drug coverage with the lowest premiums in the country.

“The Affordable Care Act is delivering on its promise of better health care for people with Medicare,” said HHS Secretary Kathleen Sebelius.  “People with Medicare who hit the doughnut hole are paying less for their prescription drugs, 17 million Americans have received free preventive services and prescription drug premiums will remain low.  These are important steps that are making a difference in the lives of millions of Americans right now.”

“Medicare beneficiaries will have more affordable prescription drug coverage next year as a result of vigorous competition in the Part D program and Medicare drug plans’ efforts to encourage seniors to choose the most affordable medicines,” said Karen Ignagni, president and CEO of America’s Health Insurance Plans.  Ignagni noted that “taxpayers are also saving billions of dollars as the total cost of the program continues to be far below original projections.”

CMS Issues Rules for Health Insurance Co-ops

Monday, August 1st, 2011

The Center for Medicare and Medicaid Services (CMS) has issued rules impacting the creation of co-ops, or private not-for-profit insurers created by Patient Protection and Affordable Care Act.  The co-ops will receive funding via $3.8 billion in government loans.  They will be run by consumers and will qualify for start-up loans if they have a high probability of becoming financially viable.  CMS will determine viability based on evaluations of their legal, operational and business plans, according to Richard Popper, director of the Office of Insurance Programs at the CMS.  Additionally, CMS will offer “solvency” loans to provide insurers with the legally and financially required reserves.  The co-ops are intended as non-commercial alternatives for insurance consumers joining the health insurance exchanges that will begin in 2014.  The rules will require that any co-ops’ profits to go to reducing their customers’ costs or improving their care.  “That’s what really makes these plans different and why Congress chose to include these in the Affordable Care Act,” Popper said.

Anyone who is confused about the status of their state’s insurance exchange can take advantage of two excellent resources for clarification.  One is a primer put out by the non-profit Kaiser Family Foundation which answers many basic questions about the online exchanges, where millions of individuals and small businesses will price and compare insurance plans starting in 2014, in clear-cut terms.  Additionally, the Commonwealth Fund provides its own explanation of how the insurance exchanges will work.

Co-ops will provide consumers with a wider range of choices, greater plan accountability and help ensure a more competitive insurance market,” said Steve Larsen, director of the Center for Consumer Information and Insurance Oversight.  This “announcement shows how the Affordable Care Act is bringing new choices and giving consumers a voice in insurance markets throughout the nation.”

The co-ops are structured to increase competition in the insurance market and provide additional options for people and small businesses looking for affordable health insurance.  Their organization is similar to that of credit unions: profits are used to benefit members of the co-op, which can include reducing premiums, improving health benefits, improving the quality of care, expanding enrollment or taking other actions to contribute to stabilizing coverage.

“The co-op program also seeks to promote improved models of care. Existing health insurance cooperatives and other business cooperatives provide possible models for the successful development of Co-ops around the country,” noted the proposed rule.  “One major barrier to continued development of this model has been the difficulty of obtaining adequate capitalization for start- up costs and state reserve requirements.  The Co-op program is designed to help overcome this major barrier to new issuer formation by providing funding for these critical activities.”

Writing on Kaiser Health News, Christopher Weaver says that “The rules would steer a total of $3.8 billion in low-interest loans to groups such as The Evergreen Project in Baltimore, seeking to launch the so-called Consumer Oriented and Operated Plans. The health department hopes at least one ‘co-op’ will launch in each state and anticipates funding a total of 57 around the country.  The strategy is that new health plans run by consumers – most board members would also have to be plan members — would find ways to improve care, rather than boost profits. The new plans, made possible by the seed money, would also compete with established insurers to drive prices down.  The Evergreen Project, named after the coffee shop where its founders held initial meetings, is among a small cadre of groups that are laying the groundwork to launch these nonprofit insurers to care for families and individuals who will be required to buy coverage under the health law — but may be hard pressed to afford it.”

Dr. Peter Beilenson, one of the founders, said The Evergreen Project has already raised $315,000 in foundation grants and completed a 16-month feasibility study.  The members are expecting a report from hired actuaries before applying for the loans to move forward.  The key factor: Could the co-op actually cost less than other insurers?  “We actually think we can bring it in” — meaning the plan’s premium prices — “under Aetna and Coventry,” Beilenson said.

Mike Leavitt,  a former Secretary of Health and Human Services and governor of Utah said that governors need to take the lead in creating health insurance exchanges or the federal government will dictate how the exchanges should be run.  “This is a profoundly important moment for states,” Leavitt said.  “States need to lead.  Too often, we have just deferred this to the federal government, and the federal government needs guidance (from the states) to do it.”  Iowa Governor Terry Branstad said Iowans are “confused and, I think, very upset with what’s going on” with healthcare reform implementation.  According to Branstad, consumers must take “ownership” of their health decisions and the costs.

What’s at Stake? Medicaid, Not Medicare

Monday, June 27th, 2011

Seventy percent of Americans oppose cuts to Medicare and 57 percent are against cutting Medicaid, even when they are aware that the programs constitute an outsized weight in the federal deficit.  Of the two wildly popular programs, Medicaid is the most vulnerable.

Writing in the Washington Post about a report from the Kaiser Family Foundation about the health of Medicare and Medicaid, Ezra Klein says “It doesn’t matter whether Eric Cantor says he’s bargaining for the Ryan budget or not.  The GOP cannot privatize and voucherize Medicare.  They can’t even get close.  It’s too easy an issue for Democrats, too dangerous an issue with seniors, and too slipshod a policy even for Michele Bachmann.  The attack on Medicaid, however, is another story.  That one might actually work.  And if it does, it’ll actually be worse.  ‘in-the-know political circles,’ says Chris Jennings, who ran President Bill Clinton’s healthcare reform efforts, ‘it’s just assumed Medicaid is going to be hit.  No one is going to want to touch Medicare.  Medicare is where the political juice is.  But we’re going to need savings.  So that leads to Medicaid.’  There are two reasons Medicaid is more vulnerable than Medicare.  The first is who it serves.  Medicaid goes to two groups of people: the poor and the disabled. Most of the program’s enrollees are kids from poor families, though most of the program’s money is spent on the small fraction of beneficiaries who are disabled and/or elderly.  These groups have one thing in common: They’re politically powerless.”

It’s a little-known fact that Medicaid covers more people than Medicare. In 2010, according to the Department of Health and Human Services, Medicaid covered 53.9 million people, compared with Medicare’s 47.3 million.  Additionally, Medicaid patients are also among society’s most vulnerable.  “Kids (and) pregnant women are the vast majority,” according to Health and Human Services Secretary Kathleen Sebelius.  “But then older seniors, many of whom are in nursing homes…and very disabled individuals” are also covered by Medicaid.

Although states and the federal government share the cost of Medicaid, what grates on some governors is the rules that come with the money.  “Governors just want flexibility to run our states,” said Republican New Jersey Governor Chris Christie at the annual National Governors Association meeting in February. “We don’t want to pay 50 percent of the cost of Medicaid and have zero percent of the authority.  And I don’t think that’s an unreasonable thing to be asking for.”  Governor Haley Barbour of Mississippi agrees.  “If I could get total flexibility, I would take a two percent cap in a heartbeat,” he said.  Barbour’s preference is to receive a lump sum – what it gets now from the federal government, plus two percent to fund Medicaid.

Dr. Donald Berwick, administrator of the Center for Medicare and Medicaid Services, (CMS) said “There’s a right way to reform Medicare and a wrong way,”  Berwick believes that the direction he is taking — modeled on his successful patient safety campaigns at the Institute for Healthcare Improvement – will bring about needed healthcare change.  The Obama administration’s efforts to improve patient safety are more or less bipartisan.  There is little cause to dispute CMS’ data: the agency spent $4.4 billion in 2009 caring for patients harmed in hospitals and an additional $26 billion on patients who were readmitted within 30 days.  The Partnership for Patients, funded through the Patient Protection and Affordable Care Act (ACA), seeks to reduce preventable injuries by 40 percent and cut hospital readmissions by 20 percent in just two years.  According to CMS, achieving the Partnership’s goals will result in 1.8 million fewer patient injuries, allow more than 1.6 million patients to recover complication-free and save up to $35 billion in health costs.

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius described contentious portions of the ACA as the inaugural steps toward entitlement reform.  Sebelius criticized proposals to transform federal Medicaid funding into block grants for states.  When some lawmakers asked her to speak about the Obama administration’s alternative proposal to rein in entitlement spending, Sebelius pointed to two provisions of the new law.  The ACA created a new board of independent experts that will recommend Medicare payment cuts.  Its recommendations will take effect automatically unless Congress blocks them — and proposes equivalent savings.  According to Sebelius, the panel represents “a big step in terms of entitlement reform that actually doesn’t potentially cause harm to our seniors.”  She also pointed to an HHS effort to create new methods of dealing with people who are eligible for both Medicare and Medicaid because those patients represent a lopsided share of the programs’ costs.

CMS Chief Dr. Donald Berwick Favors ACOs

Tuesday, January 4th, 2011

Dr. Donald Berwick, Administrator of the Center for Medicare and Medicaid Services (CMS), “can’t imagine a worse idea than repealing the Patient Protection and Affordable Care Act healthcare reform law.  “Without the individual mandate, the intention to extend coverage, especially to people with chronic illnesses, would unravel,” Berwick said in a recent speech to the Commonwealth Club of California.  According to Berwick, the requirement is “bearing your share of responsibility for your health.”

Berwick believes the new healthcare reform law “has got more resources in it and texture than I imagined.”  One of the law’s biggest opportunities, Berwick said, is accountable-care organizations (ACOs); CMS is planning to release proposed ACO regulations in January.  Berwick said that there is no single approach to creating an ACO because of differences between local resources, providers, and even geography.  “I think we are going to see a rebirth of organizations able to make care a journey and not fragmentation.  Organizations will have memories about patients, not amnesia,” Berwick said.  “Withholding needed care is one of the worst plans you can imagine.

Berwick warned that there will be two sides to the transformation that healthcare reform will bring.  One will be “authentic, they will be the real partners on a great national expedition,” he said.  Others “will become cloaks of the status quo.”  The federal government has committed $10 billion over the next decade to the new Center for Medicare and Medicaid Innovation, a program that will test new approaches – as well as models of care and payment — that can improve health services.