Short Takes On News & Events

Incomplete Face-To-Face Doctor Exams Put Home Health Agencies In Tight Spot

Medicare is paying billions of dollars to home-health providers without adequate documentation of patients’ needs by doctors, according to a new report by the Department of Health and Human Services Office of Inspector General.

The cost of caring for homebound patients is rising, and the government is trying to get a better grip on spending by requiring doctors to certify — with face to face examinations — Medicare beneficiaries’ eligibility for home health services, including intermittent skilled nursing care, physical therapy, speech therapy and part-time home health aide services. The OIG estimated that $2 billion in inappropriate payments were made in 2011 and 2012 because of inadequate compliance with the rule.

But home health agencies, which billed Medicare $19.5 billion for these services in 2010, view the rule as burdensome and vague, and worry it will impede in their ability to deliver care.

Beatriz Lamb, regional director of home health care and hospice for Franciscan St. Elizabeth Health in Indiana, said that they give care to around 120 patients and juggle documentation from about 80 doctors. “It does create delays in care, we can’t afford to go out without a face-to-face [certification] in hand and I don’t have leverage to get it done if I’m already seeing the patient,” Lamb said.

The face-to-face rule results from a provision of the Affordable Care Act and is designed to reduce inappropriate Medicare payments for home health services. The OIG’s assessment found that of the claims that required face-to-face encounters, 32 percent did not meet the Centers for Medicare & Medicaid Services rules on what doctors must document, and should not have been paid. Home health providers worry that CMS could later try to recover these overpayments.

The rule requires that certifying physician must fill out documentation that includes the physician’s title, signature and date of the face-to-face encounter. It must also include a brief narrative that describes that patient’s clinical condition and the way in which the patient’s clinical condition supports his/her home-bound status and the need for care.

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April 18th, 2014, 5:00 AM by Lisa Gillespie

Short Takes On News & Events

Biggest Insurer Shocked With Hepatitis C Costs

UnitedHealth Group spent $100 million on hepatitis C drugs in the first three months of the year, much more than expected, the company said Thursday. The news helped drive down the biggest insurance company’s stock and underscores the challenge for all health care payers in covering Sovaldi, an expensive new pill for hepatitis C.

“We’ve been surprised on the volume — the pent-up demand across all three businesses” — commercial insurance and private Medicare and Medicaid plans, said Daniel Schumacher, chief financial officer of UnitedHealth’s insurance wing. Schumacher and other executives discussed the company’s first-quarter results on a call with financial analysts.

Made by Gilead Sciences, Sovaldi costs more than $80,000 per treatment and is seen as highly effective against hepatitis C, a chronic virus infection that often leads to liver failure. But the high cost, and what increasingly looks like high demand, is straining budgets for the government-financed Medicare and Medicaid programs as well as for private insurers that had not priced the drug into this year’s premiums.

UnitedHealth bosses discussed other pressures on first-quarter profits, especially from customers who renewed 2013 policies for 2014. To avoid premium increases associated with Affordable Care Act rules that became effective this year, many customers extended their plans late last year.

President Obama also expanded the ability of policyholders to keep their plans. The result is that UnitedHealth has many more customers than expected on older plans at lower rates, squeezing profits.

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April 17th, 2014, 12:11 PM by Jay Hancock

Short Takes On News & Events

Hospitals Get Into Doctor Rating Business

After some doctors at University of Utah Health Care noticed scathing online reviews about themselves in 2012, the hospital system decided the best way to respond was by posting its patients’ ratings of physicians on the hospital’s own website.

The hospital was already randomly surveying patients about their experiences with physicians.

Now, when potential patients use online search engines to look for a University of Utah Health Care doctor, the hospital’s reviews pop up first. “We knew our patient satisfaction scores were really strong and we had a good story to share with our patients,” said Brian Gresh, senior director for interactive marketing & web at University of Utah Health Care.

Even though every University of Utah Health Care doctor scored a four- or five-star rating out of a maximum of five stars, Gresh notes that not all the published comments left by patients on the website are glowing.

While that was the first hospital system to start posting individual doctors ratings, others are contemplating the move, said Dr. James Merlino, chief experience officer, at the Cleveland Clinic. “This is clearly a trend that is coming,” he said, adding that his own institution is looking into it.

Many hospitals have surveyed patients about doctors for decades, but the data was usually only used internally. In the past few years, some hospitals including the Cleveland Clinic, have started showing doctors how they compared to each other on the ratings. “Doctors are highly competitive and no one wants to be on the bottom of the list,” Merlino said.

Online ratings of physicians haven’t caught on as much as ratings of books and movies, but medical information sites, such as Healthgrades and Vitals, and broader consumer sites including Yelp and Consumer Reports offer physician reviews. Some score doctors based on patient surveys, and some allow patients to post comments. A research letter in the Journal of the American Medical Association found that one in four patients consulted them when picking a primary care doctor in 2012.

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April 17th, 2014, 5:00 AM by Phil Galewitz

Short Takes On News & Events

Hospital Visits Fell When Seniors Got Drug Coverage

Eleven years ago Bob Bennett, then a Republican senator from Utah, made a fiscal sales pitch for including prescription drugs in Medicare coverage for seniors.

“Medicare says if you go to the hospital and run up a bill of however many tens of thousands of dollars to stay that many days, we will pay for it,” he said in June 2003. “But if you take the pill that makes the hospital visit unnecessary, we will not. That clearly doesn’t make sense.”

Researchers at the University of Illinois and the Johns Hopkins University have made the broadest test yet of Medicare Part D prescription drug program’s promise — that covering drugs would keep seniors out of the hospital.

Comparing national records from before and after 2006, when Part D kicked in, they found that drug coverage was associated with an 8 percent drop in hospital admissions and nearly as much in hospital-cost savings — an amount they calculate to be $1.5 billion a year.

But here’s what they didn’t find: any difference in death rates between the seniors who had access to drugs under Part D and those who didn’t. They thought broader drug coverage might reduce mortality.

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April 16th, 2014, 2:58 PM by Jay Hancock

Health Care In The States

Health Law Push Brings Thousands Into Colo. Medicaid Who Were Already Eligible

The big marketing push to get people enrolled in health coverage between October and March resulted in 3 million people signing up for Medicaid.

Colorado capitol by Jesse Varner via Flickr

Hundreds of thousands of those people were children who were already eligible and could have signed up even before the Affordable Care Act made coverage much more generous.

They came “out of the woodwork” to get enrolled, analysts say, thanks to the Affordable Care Act’s individual mandate and publicity around its new marketplaces.

In Colorado, nearly 23,000 such children are now getting Medicaid. Their numbers grew Colorado’s Medicaid rolls by 3 percent over last year.

Colorado is one the first of the states that are expanding their Medicaid programs to report how many people coming into the health insurance program for low-income residents could have had coverage before the health law was implemented.

State officials in Washington say 91,000 previously eligible but not enrolled residents got on Medicaid between October and March.

State Medicaid Director Sue Birch said Colorado enrolled 22,784 previously eligible kids in Medicaid and the Children’s Health Insurance Plan (CHIP) from Oct. 1 — when the state marketplace opened — until Feb. 28. Overall, including people who were eligible because of the expansion, Colorado’s Medicaid rolls grew by 23 percent during that period.

The health law called for states to expand Medicaid to anyone earning up to 138 percent of the federal poverty level (about $11,670 for an individual and $23,850 for a family of four), but the Supreme Court said that had to be voluntary. About half the states have opted not to expand.

It was widely assumed that there would be a woodwork effect, but estimates of how many previously-eligible people enrolled around the country are just now starting to come in.

The Centers for Medicare & Medicaid Services last week released a preliminary tally of Medicaid enrollment by state from October through Feb. 28.

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April 16th, 2014, 5:00 AM by Eric Whitney

Short Takes On News & Events

Survey: Health Insurance Enrollment In California More Complex Than Anticipated


Newly insured Californians felt relieved after signing up for health coverage but encountered numerous obstacles with technology and communication during the enrollment process, according to a report released Monday by the California HealthCare Foundation.

Surveyed in interviews and focus groups, consumers said they had trouble getting through to the call center, choosing a health plan and calculating their income. They also had problems with the online chat program, and many were surprised by the amount of documentation required to enroll, according to the report.

The problems were worse for Medi-Cal applicants than for those seeking private coverage through the health insurance exchange, the report said.

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April 15th, 2014, 8:07 AM by Anna Gorman

Short Takes On News & Events

State Exchange Directors Offer Enrollment Snapshots


This post was corrected and updated at 4:50 pm, April 11.

The Obama administration is touting the success of the health law’s open enrollment, which signed up  at least 7.5 million Americans for health coverage through the online insurance marketplaces. But the experience varied according to states and Families USA brought together five state exchange directors Thursday to talk about what they’ve seen so far. These states – Kentucky, New York, Washington, California and Connecticut — all had functioning exchanges and pursued that health law’s Medicaid expansion.

Bill Nold, deputy executive director at the Office of the Kentucky Health Benefit Exchange, said that there were 2,000 new enrollments on March 31 alone. So far, his office has counted 400,000 new enrollees, 315,000 of whom signed up for Medicaid. He expects those numbers to continue to go up until April 11 — when his state’s enrollment extension ends. In a last-ditch effort to up enrollment, he added, the state sent out 30,000 emails to people who had started an application but had not finished.

He said 33 percent of the Kentuckians who bought plans on the exchange were younger than 35.

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April 11th, 2014, 9:39 AM by Lisa Gillespie

Short Takes On News & Events

What Consumers Can Learn From Medicare Payment Data

Wednesday the federal government published details on Medicare’s $77 billion in payments to physicians, drug testing companies and other medical practitioners during 2012.

KHN’s Jordan Rau, who reported on what can be learned from the newly-released data, discussed Medicare payments to providers with NPR’s Melissa Block on “All Things Considered” Wednesday night. Audio of that conversation and a transcript follow.

NPR’s MELISSA BLOCK:  [Wednesday], for the first time, the agency that runs the Medicare program has released data showing how much doctors get paid by the government for everything from office visits to surgical procedures to chemotherapy. It’s a massive amount of data that may help patients learn more about how their doctor practices medicine.

The data are sure to provide some interesting insights, but there are also limits to how much can be learned. And joining me in the studio now to talk more about this is Jordan Rau with our partner Kaiser Health News. Jordan, thanks for coming in.

KHN’s JORDAN RAU: Glad to be here.

MELISSA BLOCK: Why don’t you tell us first just exactly what the government released today in this massive data dump?

JORDAN RAU: They put down an entire year’s worth of billing that doctors did to Medicare, and it’s huge. It’s 880,000 different doctors billing about $77 billion, and it’s on over 6,000 different procedures — everything from an office visit to a very complicated chemotherapy to the use of a helicopter or an airplane to transport a patient.

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April 10th, 2014, 8:37 AM by KHN Editors

Short Takes On News & Events

Alzheimer’s Disease Support Model Could Save Minn. Millions


As states eye strategies to control the costs of caring for Alzheimer’s patients, a New York model is drawing interest, and findings from a study of Minnesota’s effort to replicate it shows it could lead to significant savings and improved services.

The New York University Caregiver Intervention (NYUCI) program offers caregivers six sessions of individual and family counseling within four months of enrollment, the opportunity to participate in a weekly support group and telephone counseling when needed. Minnesota mimicked that effort with a five-year pilot program offered to 228 participating caregivers in urban and rural areas.

The study, published in the April Health Affairs, found the Minnesota program could save $966 million by 2025 if it were implemented state-wide. Cost savings were mainly achieved by keeping Alzheimer’s patients in the community and at home. The authors found that 5 percent more people would stay in these settings if the project was expanded, and 19.3 percent fewer people with dementia would die in an institution.

“These findings suggest that broader access to enhanced caregiver supports could produce a positive return on investment or be cost-effective—assuming widespread implementation, reasonable program costs and substantial caregiver participation,” study authors write.

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April 10th, 2014, 5:30 AM by Lisa Gillespie

Short Takes On News & Events

A Call For Pricey Treatment For Millions With Hepatitis C

Authors of the first-ever global hepatitis C guidelines went big Tuesday, advocating for worldwide use of two of the most expensive specialty drugs in the world.

The new guidelines, from the World Health Organization, give strong endorsement to the two newest medicines. Gilead Science’s Sovaldi costs $1,000 per pill/$84,000 for a 12-week course of treatment and Olysio, Janssen Pharmaceuticals, $66,360 for its three-month course.

The high prices have ignited a firestorm of objection. In the United States, doctors and insurers argue that the cost of the drugs will make their widespread use impossible. And critics say even if the prices are heavily discounted in other countries, the drugs will still be unaffordable in most of the world.

The WHO endorsement of treatment with Sovaldi and Olysio was made without taking the cost of the two drugs into consideration. That’s because the price of the drugs outside the U.S. was unknown in December, when the WHO panel wrapped up its work.

But the price of the drugs isn’t the only issue. The WHO recommends that all 150 million or so people around the globe with chronic hepatitis C infection be assessed for treatment — a gargantuan task in itself. Authors of the report are quick to acknowledge that neither the assessment of people’s health status nor actual treatment will happen anytime soon.

“A lot has to happen for this to really take off in a big way,” says the guidelines’ chief architect, Dr, Stefan Wiktor. “Even if prices came down dramatically tomorrow, that doesn’t mean there would be an immediate rush to treatment.”

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April 9th, 2014, 8:43 AM by Richard Knox