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HHS OIG — Annual Fee on Branded Prescription Drug Companies Under the Affordable Care Act

April 23, 2014 Comments off

Annual Fee on Branded Prescription Drug Companies Under the Affordable Care Act
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
Section 9008 of the Affordable Care Act (ACA), as amended, directs branded prescription drug companies to pay to the Secretary of the Treasury fees totaling $2.5 billion in 2011, $2.8 billion in 2012, and $2.8 billion in 2013. Companies are required to pay their fees to the Department of the Treasury (Treasury) each year by September 30. An amount equal to the fees received by Treasury each year is to be transferred to the Federal Supplementary Medical Insurance (Medicare Part B) Trust Fund (hereinafter referred to as the Trust Fund). The total annual fee amount to be paid will rise to $4.1 billion in 2018, then will return to $2.8 billion in 2019 and remain at that level thereafter.

HOW WE DID THIS STUDY
We requested from CMS the total amount received by the Trust Fund for the 2011 and 2012 fee years and the dates these transfers were completed. We then compared these data to the Trust Fund data publicly available on Treasury’s Web site. We also requested CMS’s policies and procedures, conducted interviews, and sent questionnaires to the agency regarding these fees.

WHAT WE FOUND
We found that the Trust Fund received $2.5 billion for the 2011 fee, which equals the full amount that was to be paid by the companies for 2011. Of this amount, $1.876 billion was received by the Trust Fund in September 2011 and $624 million was received in December 2011. For the 2012 fee, the Trust Fund received all but $245,000 of the $2.8 billion amount that the ACA provides for the 2012 fee. The Trust Fund received $2.184 billion in September 2012, $603 million in April 2013, and $13 million in May 2013. According to CMS, after we sent our data request for the 2011 and 2012 fee years, the Trust Fund received approximately $2.6 billion in October 2013 and $199 million in December 2013, which is all but $693,000 of the $2.8 billion amount that the ACA provides for the 2013 fee. This means that between September 2011 and December 2013, the Trust Fund received all but $938,000 of the total $8.1 billion amount the ACA provides for the first 3 fee years. For the 2011 and 2012 fees, CMS used data that it received from Treasury to report on the fee’s activity and make actuarial projections.

WHAT WE CONCLUDE
Although the funds from the annual fee are allocated to the Part B Trust Fund, the ACA grants to Treasury the responsibility of administering the fee process, including transferring the fee to the Trust Fund. To the extent that the fees were not in the Trust Fund, the Trust Fund may have missed an opportunity to earn interest income on these fees. Our results indicate that it may be beneficial for CMS to periodically monitor the status of this fee in the Trust Fund, and to contact Treasury if CMS finds that the full amount to be collected under the ACA each year has not been received.

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Offshore Outsourcing of Administrative Functions by State Medicaid Agencies

April 18, 2014 Comments off

Offshore Outsourcing of Administrative Functions by State Medicaid Agencies
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
Outsourcing occurs when State Medicaid agencies enter into agreements with contractors to perform administrative functions. Outsourcing can occur inside the United States (domestic outsourcing) or outside (offshore outsourcing) and can be direct (when a Medicaid agency contracts with an offshore contractor) or indirect (when a Medicaid agency’s contractor subcontracts to an offshore contractor). There are no Federal regulations that prohibit the offshore outsourcing of Medicaid administrative functions. However, the Health Insurance Portability and Accountability Act (HIPAA) requires covered entities to have business associate agreements (BAAs) to protect personal health information (PHI).

HOW WE DID THIS STUDY
We conducted a survey of 56 Medicaid agencies, including those of the District of Columbia and the U.S. territories. We asked Medicaid agencies (1) whether they had any policies, Executive Orders, State laws, or contract requirements (collectively, “requirements”) addressing the outsourcing of administrative functions offshore and (2) whether they directly or indirectly outsourced administrative functions offshore. For Medicaid agencies with outsourcing requirements, we asked whether these requirements address PHI and whether the Medicaid agencies monitor contractors’ compliance with the requirements. We reviewed the Medicaid agencies’ requirements and BAAs. For the Medicaid agencies that outsource offshore, we asked what types of administrative functions are outsourced offshore.

WHAT WE FOUND
Only 15 of 56 Medicaid agencies have some form of State-specific requirement that addresses the outsourcing of administrative functions offshore. The remaining 41 Medicaid agencies reported no offshore outsourcing requirements and do not outsource administrative functions offshore. Among the 15 Medicaid agencies with requirements, 4 Medicaid agencies prohibit the outsourcing of administrative functions offshore and 11 Medicaid agencies allow it. The 11 Medicaid agencies that allow offshore outsourcing of administrative functions each maintain BAAs with contractors, which is a requirement under HIPAA. Among other things, BAAs are intended to safeguard PHI. These 11 Medicaid agencies do not have additional State requirements that specifically address safeguarding PHI. Seven of the eleven Medicaid agencies reported outsourcing offshore through subcontractors, but none reported sending PHI offshore. If Medicaid agencies engage in offshore outsourcing of administrative functions that involve PHI, it could present potential vulnerabilities. For example, Medicaid agencies or domestic contractors that send PHI offshore may have limited means of enforcing provisions of BAAs that are intended to safeguard PHI. Although some countries may have privacy protections greater than those in the United States, other countries may have limited or no privacy protections.

HHS OIG — Limited Compliance With Medicare’s Home Health Face to Face Documentation Requirements

April 15, 2014 Comments off

Limited Compliance With Medicare’s Home Health Face to Face Documentation Requirements
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
The Patient Protection and Affordable Care Act (ACA) requires that physicians (or certain practitioners working with them) who certify beneficiaries as eligible for Medicare home health services document-as a condition of payment for home health services-that face-to-face encounters with those beneficiaries occurred. This study (1) determined the extent to which physicians who certified home health care documented the face-to-face encounters, (2) described the nature of face-to-face documentation, and (3) assessed CMS’s oversight of the face-to-face requirement.

HOW WE DID THIS STUDY
We reviewed 644 face-to-face encounter documents to analyze the extent to which the documents confirmed encounters and contained the required elements. We interviewed the four Home Health and Hospice Medicare Administrative Contractors (HH MACs) to describe how they ensure that home health agencies met the face-to-face encounter requirements. We also reviewed guidance documents and policies from CMS or the HH MACs about monitoring the face-to-face requirement.

WHAT WE FOUND
For 32 percent of home health claims that required face-to-face encounters, the documentation did not meet Medicare requirements, resulting in $2 billion in payments that should not have been made. Furthermore, physicians inconsistently completed the narrative portion of the face to face documentation. Some face-to-face documents provide information that, although not required by Medicare, could be useful, such as a printed name for the physician and a list of the home health services needed. CMS oversight of the face-to-face requirement is minimal.

WHAT WE RECOMMEND
We recommend that CMS (1) consider requiring a standardized form to ensure that physicians include all elements required for the face-to-face documentation, (2) develop a specific strategy to communicate directly with physicians about the face-to-face requirement, and (3) develop other oversight mechanisms for the face-to-face requirement. CMS concurred with all of our recommendations.

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New State-by-State Analysis: 32 Million Were Underinsured in 2012, Including 4 Million Middle-Income People; Nearly 80 Million in Total Lacked Health Insurance or Were Underinsured, Ranging from 14 Percent in Massachusetts to 38 Percent in New Mexico and Texas

April 11, 2014 Comments off

New State-by-State Analysis: 32 Million Were Underinsured in 2012, Including 4 Million Middle-Income People; Nearly 80 Million in Total Lacked Health Insurance or Were Underinsured, Ranging from 14 Percent in Massachusetts to 38 Percent in New Mexico and Texas
Source: Commonwealth Fund

Thirty-two million people under age 65 were underinsured in the U.S. in 2012, meaning they had health coverage but it provided inadequate protection against high health care costs relative to their income, a new Commonwealth Fund report finds. The first report to examine the underinsured at the state level, it finds that the rate of underinsured ranged from a low of 8 percent in New Hampshire to highs of 16 percent in Mississippi and Tennessee and 17 percent in Idaho and Utah.

Low- and middle-income families were most likely to be affected: 13 percent—4 million—of the underinsured were middle-income, earning between about $47,000 and $95,000 for a family of four, and 81 percent—26 million—were low-income, earning less than 200 percent of the federal poverty level, or under $47,000 a year for a family of four.

In addition, 47 million people were uninsured in 2012—a decline of nearly 2 million from 2010, likely due in large part to the Affordable Care Act’s early provision to expand dependent coverage for young adults.

Before the major expansions of the ACA began to be implemented this year, a total of 79 million people under 65 were uninsured or underinsured, and therefore at risk for not being able to afford needed health care or for facing debt from medical bills in 2012. Nationally, nearly one of three (29%) people were uninsured or underinsured, ranging from 14 percent in Massachusetts to 36 to 38 percent in Florida, Idaho, Nevada, New Mexico, and Texas.

The Affordable Care Act’s Medicaid expansion and health insurance reforms are appropriately targeted to those Americans who are most likely to be unable to afford insurance or needed health care, according to the report, America’s Underinsured: A State-by-State Look at Health Insurance Affordability Prior to the New Coverage Expansions. Based on their incomes alone, 20 million of the underinsured in 2012, as well as 24 million of the uninsured, would qualify for Medicaid under the Affordable Care Act.

However, millions who are poor will not have any new coverage options. In states choosing not to expand Medicaid, more than 15 million underinsured and uninsured people have incomes below poverty—earning less than $23,550 a year for a family of four

Financial Burden of Medical Spending by State and the Implications of the 2014 Medicaid Expansions

April 10, 2014 Comments off

Financial Burden of Medical Spending by State and the Implications of the 2014 Medicaid Expansions
Source: Urban Institute

This study is the first to offer a detailed look at medical spending burden levels, defined as total family medical out-of-pocket spending as a proportion of income, for each state. It further investigates which states have greater shares of individuals with high burden levels and no Medicaid coverage, but would be Medicaid eligible under the 2014 rules of the Affordable Care Act should their state choose to participate in the expansion. This work suggests which states have the largest populations likely to benefit, in terms of lowering medical spending burden, from participating in the 2014 adult Medicaid expansions.

Participation Rises in Medicare Physician Quality Reporting System and Electronic Prescribing Incentive Program

April 9, 2014 Comments off

Participation Rises in Medicare Physician Quality Reporting System and Electronic Prescribing Incentive Program
Source: U.S. Department of Health and Human Services (Centers for Medicare & Medicaid Services)

The Centers for Medicare & Medicaid Services (CMS) today released the 2012 Physician Quality Reporting System and Electronic Prescribing (eRx) Experience Report, showing a significant increase in participation in two key programs that allow eligible professionals to earn incentive payments through voluntary participation.

“Our physician and other clinician quality programs reached new records this year with over 430,000 professionals participating in the Physician Quality Reporting System and over 340,000 e-prescribing,” said Patrick Conway, M.D. deputy Administrator for innovation and quality and chief medical officer at CMS. “Clinicians are actively measuring and reporting on quality, and CMS is in the beginning stages of adding this information to the Physician Compare website, which can be viewed by patients. Measuring, transparently sharing, and improving quality performance is key to a better health system.”

The full report can be found at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/Downloads/2012-PQRS-and-eRx-Experience-Report.zip

The Physician Quality Reporting System (PQRS) has been using incentive payments, and will begin to use payment adjustments in 2015, to encourage eligible health care professionals to report on designated quality measures. The Electronic Prescribing (eRx) Incentive Program used a combination of incentive payments and payment adjustments to encourage electronic prescribing by eligible professionals.

New From the GAO

April 8, 2014 Comments off

New GAO Reports and Testimonies
Source: Government Accountability Office

Reports

1. Medicare: Second Year Update for CMS’s Durable Medical Equipment Competitive Bidding Program Round 1 Rebid. GAO-14-156, March 7.
http://www.gao.gov/products/GAO-14-156
Highlights - http://www.gao.gov/assets/670/661475.pdf

2. 2014 Annual Report: Additional Opportunities to Reduce Fragmentation, Overlap, and Duplication and Achieve Other Financial Benefits. GAO-14-343SP, April 8.
http://www.gao.gov/products/GAO-14-343SP
Podcast - http://www.gao.gov/multimedia/podcasts/662283

3. Aviation Safety: FAA Should Improve Usability of its Online Application System and Clarity of the Pilot’s Medical Form. GAO-14-330, April 8.
http://www.gao.gov/products/GAO-14-330
Highlights - http://www.gao.gov/assets/670/662388.pdf

4. Military Capabilities: Navy Should Reevaluate Its Plan to Decommission the USS Port Royal. GAO-14-336, April 8.
http://www.gao.gov/products/GAO-14-336
Highlights - http://www.gao.gov/assets/670/662377.pdf

5. Information Security: IRS Needs to Address Control Weaknesses That Place Financial and Taxpayer Data at Risk. GAO-14-405, April 8
http://www.gao.gov/products/GAO-14-405
Highlights - http://www.gao.gov/assets/670/662372.pdf
Podcast - http://www.gao.gov/multimedia/podcasts/662350

Testimonies

1. Paid Tax Return Preparers: In a Limited Study, Preparers Made Significant Errors, by James R. McTigue Jr., director, strategic issues, before the Senate Committee on Finance. GAO-14-467T, April 8.
http://www.gao.gov/products/GAO-14-467T
Highlights - http://www.gao.gov/assets/670/662357.pdf

2. Tobacco Products: FDA Spending and New Product Review Time Frames, by Marcia Crosse, director, health care, before the Subcommittee on Health, House Committee on Energy and Commerce. GAO-14-508T, April 8.
http://www.gao.gov/products/GAO-14-508T
Highlights - http://www.gao.gov/assets/670/662361.pdf

3. Government Efficiency and Effectiveness: Opportunities to Reduce Fragmentation, Overlap, and Duplication and Achieve Other Financial Benefits, by Gene L. Dodaro, Comptroller General of the United States, before the House Committee on Oversight and Government Reform. GAO-14-478T, April 8.
http://www.gao.gov/products/GAO-14-478T
Highlights - http://www.gao.gov/assets/670/662367.pdf

HHS OIG — Questionable Billing for Medicare Electrodiagnostic Tests

April 8, 2014 Comments off

Questionable Billing for Medicare Electrodiagnostic Tests
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
In 2011, Medicare paid approximately $486 million to 21,700 physicians who billed for electrodiagnostic tests for 877,000 beneficiaries. Electrodiagnostic tests are used to evaluate patients who may have nerve damage. Recent investigations have found that electrodiagnostic testing is an area vulnerable to fraud, waste, and abuse. For example, in 2011, following work by the Medicare Fraud Strike Force, a group of physicians was charged with fraudulently billing Medicare $113 million for false claims, including claims for electrodiagnostic tests. CMS issues comparative billing reports to providers for a variety of services, including electrodiagnostic testing. Such reports are intended to proactively educate providers and to help them identify and correct errors in their billing.

HOW WE DID THIS STUDY
We developed seven measures of questionable billing on the basis of past OIG work and input from CMS staff. We analyzed Medicare 2011 electrodiagnostic test claims to identify physicians who had unusually high billing for at least one of these measures. We also determined whether physicians with questionable billing for electrodiagnostic tests received comparative billing reports in 2011 for such tests. Finally, we identified the geographical areas with the highest amounts of questionable billing.

WHAT WE FOUND
In 2011, 4,901 physicians had questionable billing for Medicare electrodiagnostic tests totaling $139 million. Additionally, we found that approximately 20 percent of these physicians received comparative billing reports in 2011 on the basis of their 2010 billing for electrodiagnostic tests. Finally, physicians in the New York, Los Angeles, and Houston areas had the highest total questionable billing for Medicare electrodiagnostic tests in 2011.

WHAT WE RECOMMEND
We recommend that CMS (1) increase its monitoring of billing for electrodiagnostic tests, (2) provide additional guidance and education to physicians regarding electrodiagnostic tests, and (3) take appropriate action regarding physicians whom we identified as having inappropriate or questionable billing. CMS partially concurred with two of our recommendations and concurred with the third recommendation.

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage — United States, 2008–2014

March 30, 2014 Comments off

State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage — United States, 2008–2014
Source: Morbidity and Mortality Weekly Report (CDC)

Medicaid enrollees have a higher smoking prevalence than the general population (30.1% of adult Medicaid enrollees aged <65 years smoke, compared with 18.1% of U.S. adults of all ages), and smoking-related disease is a major contributor to increasing Medicaid costs (1,2). Evidence-based cessation treatments exist, including individual, group, and telephone counseling and seven Food and Drug Administration (FDA)–approved medications (3). A Healthy People 2020 objective (TU-8) calls for all state Medicaid programs to adopt comprehensive coverage of these treatments.* However, most states do not provide such coverage (4). To monitor trends in state Medicaid cessation coverage, the American Lung Association† collected data on coverage of all evidence-based cessation treatments except telephone counseling§ by state Medicaid programs (for a total of nine treatments), as well as data on barriers to accessing these treatments (such as charging copayments or limiting the number of covered quit attempts) from December 31, 2008, to January 31, 2014. As of 2014, all 50 states and the District of Columbia cover some cessation treatments for at least some Medicaid enrollees, but only seven states cover all nine treatments for all enrollees. Common barriers in 2014 include duration limits (40 states for at least some populations or plans), annual limits (37 states), prior authorization requirements (36 states), and copayments (35 states). Comparing 2008 with 2014, 33 states added treatments to coverage, and 22 states removed treatments from coverage; 26 states removed barriers to accessing treatments, and 29 states added new barriers.¶ The evidence from previous analyses suggests that states could reduce smoking-related morbidity and health-care costs among Medicaid enrollees by providing Medicaid coverage for all evidence-based cessation treatments, removing all barriers to accessing these treatments, promoting the coverage, and monitoring its use (3,5–8).

CMS System for Sharing Information About Terminated Providers Needs Improvement

March 28, 2014 Comments off

CMS System for Sharing Information About Terminated Providers Needs Improvement
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
The Patient Protection and Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a process for sharing information about terminated providers. To meet this requirement, CMS established a Web-based portal, the Medicaid and Children’s Health Insurance Program State Information Sharing System (MCSIS). Sharing terminated provider data among States prevents terminated providers in one State from enrolling in another State. CMS and State agencies can submit information about providers that meet CMS’s criteria for having been terminated “for cause” from Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). State Medicaid agencies can use these data to identify these providers and subsequently terminate them from their Medicaid programs as required under another section of the ACA. In November 2013, subsequent to the timeframe we examined for this study, CMS revised its process for sharing information about terminated providers. The findings and recommendations in this report remain relevant to the new process.

HOW WE DID THIS STUDY
We examined all provider records contained in MCSIS as of June 1, 2013. We (1) determined the extent to which MCSIS contained records submitted by CMS and State Medicaid agencies; (2) identified records that did not meet CMS criteria for reporting providers terminated “for cause” from Medicare, Medicaid, or CHIP; and (3) assessed whether records had complete identifying information about providers, including National Provider Identifiers (NPIs), provider types, and provider addresses.

WHAT WE FOUND
As of June 1, 2013, MCSIS contained records on terminated providers submitted by CMS and 33 State Medicaid agencies and did not contain records from the remaining State Medicaid agencies. Contrary to CMS guidance, about one-third of the 6,439 records in MCSIS did not relate to providers terminated “for cause.” Over half of MCSIS records did not contain NPIs, a critical data element for accurately identifying providers. Additionally, one-third of MCSIS records did not identify the provider types and one quarter had no provider addresses.

WHAT WE RECOMMEND
Our findings suggest that CMS’s process for sharing information on terminated providers needs improvement to make it more useful to State Medicaid agencies in identifying providers that must be terminated pursuant to Federal law because they were terminated “for cause” by Medicare, Medicaid, or CHIP. Therefore, we recommend that CMS (1) require each State Medicaid agency to report all terminated providers, (2) ensure that the shared information contains only records that meet CMS’s criteria for inclusion, and (3) take action to improve the completeness of records shared through the process. CMS concurred with all recommendations.

CBO — Letter to the Honorable Paul Ryan Regarding Federal Spending for Major Mandatory Spending Programs and Tax Credits that are Primarily Means-Tested

March 25, 2014 Comments off

Letter to the Honorable Paul Ryan Regarding Federal Spending for Major Mandatory Spending Programs and Tax Credits that are Primarily Means-Tested
Source: Congressional Budget Office

Federal spending for each of the government’s major mandatory spending programs and tax credits that are primarily means-tested (that is, spending programs and tax credits that provide cash payments or assistance in obtaining health care, food, or education to people with relatively low income or few assets). Table 1 shows CBO’s baseline projections for the 2014–2024 period; Table 2 shows historical spending data from 2004 through 2013, along with CBO’s estimates for 2014.

The tables include total spending for mandatory programs that are primarily not means-tested, but they do not include separate entries for individual programs in that group that have means-tested components (for example, student loans and some portions of Medicare, other than low-income subsidies for Part D). They also do not include means-tested programs that are discretionary (for example, the Section 8 housing assistance programs and the Low Income Home Energy Assistance Program). However, the tables show discretionary spending for the Pell Grant program as a memorandum item because that program has both discretionary and mandatory spending components and the amount of the mandatory Pell grant component is partially dependent on the annual amount of discretionary funding.

In CBO’s latest baseline projections, published in The Budget and Economic Outlook: 2014 to 2024 (February 2014), mandatory outlays for both means-tested and non-means-tested programs are projected to grow over the next decade at an average annual rate of 5.4 percent (see Table 1).

Overall, the growth rates projected for total mandatory spending over the coming decade are slower than those experienced in the past 10 years—by about one-half percentage point per year, on average. Over the 2005–2014 period, CBO estimates that total mandatory outlays will have increased at an average annual rate of 6.0 percent—means-tested programs by an average of 6.8 percent per year and non-means-tested programs by 5.7 percent per year (see Table 2).

HHS OIG — Compendium of Priority Recommendations

March 19, 2014 Comments off

Compendium of Priority Recommendations
Source: U.S. Department of Health and Human Services, Office of Inspector General

The Compendium of Priority Recommendations presents opportunities to achieve cost savings, improve program management, and ensure quality of care and safety of beneficiaries. The 25 broad “Priority Recommendations” we identified for the March 2104 edition derive from more specific recommendations that OIG has made in audit and evaluation reports. Those more specific recommendations, or action steps, are included in the summary of each broad recommendation, and the underlying reports are referenced. The 25 recommendations are generally grouped according to the underlying HHS program or operation; thus, they are not internally ranked and so do not reflect relative priority among the 25.

OIG’s audits and evaluations do not routinely project the annual cost savings that could be realized at program level from implementing the recommendations. However, reports are indicative of the extent to which policies and methodologies may be less than effective and in need of corrective action. Actual savings to be achieved depend on the scope of the legislative, regulatory, or administrative implementing actions.

In years prior to 2007, information about recommendations was provided in OIG’s “Red Book” (unimplemented monetary recommendations) and “Orange Book” (unimplemented nonmonetary recommendations). The “Red Book” focused on significant Office of Inspector General (OIG) recommendations to save costs and the “Orange Book” focused on recommendations to improve HHS programs.

Potential Therapeutic Competition in Community-Living Older Adults in the U.S.: Use of Medications That May Adversely Affect a Coexisting Condition

March 18, 2014 Comments off

Potential Therapeutic Competition in Community-Living Older Adults in the U.S.: Use of Medications That May Adversely Affect a Coexisting Condition
Source: PLoS ONE

Objective
The 75% of older adults with multiple chronic conditions are at risk of therapeutic competition (i.e. treatment for one condition may adversely affect a coexisting condition). The objective was to determine the prevalence of potential therapeutic competition in community-living older adults.

Methods
Cross-sectional descriptive study of a representative sample of 5,815 community-living adults 65 and older in the U.S, enrolled 2007–2009. The 14 most common chronic conditions treated with at least one medication were ascertained from Medicare claims. Medication classes recommended in national disease guidelines for these conditions and used by ≥2% of participants were identified from in-person interviews conducted 2008–2010. Criteria for potential therapeutic competition included: 1), well-acknowledged adverse medication effect; 2) mention in disease guidelines; or 3) report in a systematic review or two studies published since 2000. Outcomes included prevalence of situations of potential therapeutic competition and frequency of use of the medication in individuals with and without the competing condition.

Results
Of 27 medication classes, 15 (55.5%) recommended for one study condition may adversely affect other study conditions. Among 91 possible pairs of study chronic conditions, 25 (27.5%) have at least one potential therapeutic competition. Among participants, 1,313 (22.6%) received at least one medication that may worsen a coexisting condition; 753 (13%) had multiple pairs of such competing conditions. For example, among 846 participants with hypertension and COPD, 16.2% used a nonselective beta-blocker. In only 6 of 37 cases (16.2%) of potential therapeutic competition were those with the competing condition less likely to receive the medication than those without the competing condition.

Conclusions
One fifth of older Americans receive medications that may adversely affect coexisting conditions. Determining clinical outcomes in these situations is a research and clinical priority. Effects on coexisting conditions should be considered when prescribing medications.

See: One in 5 older Americans take medications that work against each other (EurekAlert!)

Medicaid Fraud Control Units Fiscal Year 2013 Annual Report

March 11, 2014 Comments off

Medicaid Fraud Control Units Fiscal Year 2013 Annual Report
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
The Department of Health and Human Services (HHS) OIG is the designated Federal agency that oversees State Medicaid Fraud Control Units (MFCU or Unit). This MFCU Fiscal Year (FY) 2013 Annual Report highlights statistical achievements from the investigations and prosecutions conducted by the 50 MFCUs nationwide. The report also explores relevant policy issues that affect Medicaid fraud work and describes oversight activities undertaken by OIG. This report represents a new effort by OIG to compile in one document information about MFCU activities and results, and we anticipate issuing annual reports for future years.

HOW WE DID THIS STUDY
We based the information in this report on an analysis of data from six sources: (1) Quarterly Statistical Reports submitted by Units; (2) supplemental data collected from Units for this FY 2013 MFCU Annual Report; (3) HHS OIG exclusion data; (4) information gathered through onsite reviews; (5) MFCUs’ Memorandums of Understanding (MOUs) with their State Medicaid agencies; and (6) the annual reports of individual MFCUs. All statistical information is current as of January 31, 2014, except where otherwise noted.

WHAT WE FOUND
In FY 2013, MFCUs nationwide reported a total of 1,341 criminal convictions in cases involving Medicaid fraud and patient abuse and neglect, and criminal recoveries reached nearly $1 billion. Criminal convictions involved a variety of provider types, most notably home health agencies. MFCUs also obtained 879 civil settlements and judgments in FY 2013, and civil recoveries totaled over $1.5 billion. Civil settlements and judgments involved a variety of provider types, most notably pharmaceutical companies. MFCUs are an important source of referrals to the OIG for purposes of provider exclusions; for over 1,000 Medicaid providers convicted in MFCU cases, OIG took further action to exclude them from all Federal health care programs, including Medicare, in FY 2013.

We found that a lack of fraud referrals to MFCUs from Medicaid managed care organizations (MCOs) presents challenges; Unit officials expressed concern that some MCOs may not have incentive to refer providers suspected of fraud. We also found that recent provider payment suspension rules enacted by the Patient Protection and Affordable Care Act (ACA) require more coordination between MFCUs and State Medicaid agencies. Finally, in its oversight role during FY 2013, OIG conducted 10 onsite reviews of Units, published 8 reports on onsite reviews, issued regulations to allow data mining by MFCUs, and proposed additional authorities for Units to investigate allegations of patient abuse and neglect.

Characteristics of Noninstitutionalized DI and SSI Program Participants, 2010 Update (released February 2014)

March 10, 2014 Comments off

Characteristics of Noninstitutionalized DI and SSI Program Participants, 2010 Update
Source: Social Security Administration

The Social Security Administration (SSA) produces several statistical publications based on the data used to administer the Disability Insurance (DI) and Supplemental Security Income (SSI) programs. Although these data are extensive, they do not capture many of the economic and demographic characteristics of program participants. To better understand those beneficiary populations, SSA matches information from its administrative records with data collected by the Census Bureau in the Survey of Income and Program Participation (SIPP). DeCesaro and Hemmeter (2008) contains tables describing the characteristics of DI and SSI program participants based on 2002 data. This note updates those tables with data for 2010.

New From the GAO

March 10, 2014 Comments off

New GAO Reports
Source: Government Accountability Office

1. DOD Business Systems Modernization: Air Force Business System Schedule and Cost Estimates. GAO-14-152,February 7.
http://www.gao.gov/products/GAO-14-152
Highlights - http://www.gao.gov/assets/670/660747.pdf

2. Medicare: Nurse Anesthetists Billed for Few Chronic Pain Procedures; Implementation of CMS Payment Policy Inconsistent. GAO-14-153, February 7.
http://www.gao.gov/products/GAO-14-153
Highlights - http://www.gao.gov/assets/670/660739.pdf

3. Telecommunications: Federal Broadband Deployment Programs and Small Business. GAO-14-203, February 7.
http://www.gao.gov/products/GAO-14-203
Highlights - http://www.gao.gov/assets/670/660744.pdf

4. Joint Professional Military Education: Opportunities Exist for Greater Oversight and Coordination of Associated Research Institutions. GAO-14-216, March 10.
http://www.gao.gov/products/GAO-14-216
Highlights - http://www.gao.gov/assets/670/661507.pdf

5. Student and Exchange Visitor Program: DHS Needs to Assess Risks and Strengthen Oversight of Foreign Students with Employment Authorization. GAO-14-356, February 27.
http://www.gao.gov/products/GAO-14-356
Highlights - http://www.gao.gov/assets/670/661191.pdf

6. Countering Overseas Threats: Gaps in State Department Management of Security Training May Increase Risk to U.S. Personnel. GAO-14-360, March 10.
http://www.gao.gov/products/GAO-14-360
Highlights - http://www.gao.gov/assets/670/661488.pdf

High-Risk Security Vulnerabilities Identified During Reviews of Information Technology General Controls at State Medicaid Agencies

March 7, 2014 Comments off

High-Risk Security Vulnerabilities Identified During Reviews of Information Technology General Controls at State Medicaid Agencies
Source: U.S. Department of Health and Human Services, Office of Inspector General

This report summarizes the high-risk security vulnerabilities that we noted as audit findings in our previous, restricted reviews of information system general controls related to the Medicaid Management Information Systems (MMIS) at 10 State agencies between calendar years 2010 and 2012. Information system general controls are the structure, policies, and procedures that apply to an entity’s overall computer operations, ensure proper operations of information systems, and create a secure environment for application systems. Some primary objectives of general controls are to safeguard data, protect computer applications, prevent unauthorized access to system software, and ensure continued computer operations after unexpected interruptions.

We identified a total of 79 findings in the 10 State Medicaid agencies whose information system general controls we audited between calendar years 2010 and 2012. We grouped these 79 individual findings into 15 security control areas within 3 information system general control categories: entitywide controls, access controls, and network operations controls. In the area of entitywide controls, we identified significant and pervasive findings involving the need to develop or strengthen formal, comprehensive plans for system security, contingency planning, and configuration management, among other findings. Findings in the area of access controls included frequently-noted vulnerabilities related to logical access and user account management, login identification and authentication, and remote access. In the area of network operations controls, we identified significant and pervasive findings regarding the need for formalized policies and procedures for network device management and patch management, among other findings.

In some of the general control areas, we noted findings with similar vulnerabilities in different State agencies, which indicated that the vulnerabilities identified in these findings were systemic and pervasive. However, because we did not test all of the same information system general controls at each State agency and because we did not use a methodology that would permit us to extrapolate our findings to all State agencies, we cannot conclude that all Medicaid information system security environments have similar vulnerabilities.

Officials from several State agencies described some common causes when we discussed these findings with them. They pointed most frequently to resource constraints that made information system security a lower priority. Officials also described a lack of formal policies and procedures when explaining the causes of the vulnerabilities. The effectiveness of these information system general controls directly affects the State agencies’ ability to sustain secure Medicaid systems.

Less Than Half of Part D Sponsors Voluntarily Reported Data on Potential Fraud and Abuse

March 5, 2014 Comments off

Less Than Half of Part D Sponsors Voluntarily Reported Data on Potential Fraud and Abuse
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
In 2011, total expenditures for the Medicare Part D prescription drug program were $67.1 billion. CMS contracts with plan sponsors to provide Part D coverage to beneficiaries. The Office of Inspector General has recommended that CMS require sponsors to report data on potential fraud and abuse related to Part D to CMS. Rather than requiring these data, CMS encouraged sponsors to voluntarily report them beginning in 2010. This study provides information on the fraud and abuse data reported by sponsors and on whether CMS used these data to monitor or oversee the Part D program.

HOW WE DID THIS STUDY
We accessed CMS’s Healthcare Plan Management System to download data on potential fraud and abuse reported by Part D plan sponsors from 2010 through 2012. We also accessed CMS’s public files of Part D enrollment to determine the number of beneficiaries enrolled in Part D plans from 2010 through 2012. We reviewed the sponsors’ aggregate data to determine the number and percentage of sponsors that reported data on potential fraud and abuse each year. In addition, we surveyed CMS about its review and use of these reported data.

WHAT WE FOUND
More than half of Part D plan sponsors did not report data on potential fraud and abuse between 2010 and 2012. Of those sponsors that did report data, more than one-third did not identify any incidents for at least one of their reporting years. In total, sponsors reported identifying 64,135 incidents of potential fraud and abuse between 2010 and 2012. Sponsors’ identification of such incidents varied significantly, from 0 to almost 14,000 incidents a year. CMS requires sponsors to conduct inquiries and implement corrective actions in response to incidents of potential fraud and abuse; however, 28 percent of Part D plan sponsors reported performing none of these actions between 2010 and 2012. Although CMS reported that it conducted basic summary analyses of the data on potential fraud and abuse, it did not perform quality assurance checks on the data or use them to monitor or oversee the Part D program.

WHAT WE RECOMMEND
We recommend that CMS (1) amend regulations to require sponsors to report to CMS their identification of and response to potential fraud and abuse; (2) provide sponsors with specific guidelines on how to define and count incidents, related inquiries, and corrective actions; (3) review data to determine why certain sponsors reported especially high or low numbers of incidents, related inquiries, and corrective actions; and (4) share sponsors’ data on potential fraud and abuse with all sponsors and law enforcement. CMS did not concur with the first recommendation, partially concurred with the second and fourth recommendations, and concurred with the third recommendation.

New From the GAO

March 4, 2014 Comments off

New From the GAO
Source: Government Accountability Office

Reports

1. Climate Change: Energy Infrastructure Risks and Adaptation Efforts. GAO-14-74, January 31.
http://www.gao.gov/products/GAO-14-74
Highlights – http://www.gao.gov/assets/670/660559.pdf

2. Human Capital: Agencies Should More Fully Evaluate the Costs And Benefits Of Executive Training. GAO-14-132, January 31.
http://www.gao.gov/products/GAO-14-132
Highlights – http://www.gao.gov/assets/670/660579.pdf

3. Countering Overseas Threats: DOD and State Need to Address Gaps in Monitoring of Security Equipment Transferred to Lebanon. GAO-14-161, February 26.
http://www.gao.gov/products/GAO-14-161
Highlights – http://www.gao.gov/assets/670/661162.pdf

4. The Air Force’s Evolved Expendable Launch Vehicle Competitive Procurement. GAO-14-377R, March 4.
http://www.gao.gov/products/GAO-14-377R

Testimony

1. Medicare: Contractors and Private Plans Play a Major Role in Administering Benefits, by Kathleen M. King and James Cosgrove, directors, health care, before the Subcommittee on Health, House Committee on Energy and Commerce. GAO-14-417T, March 4.
http://www.gao.gov/products/GAO-14-417T
Highlights – http://www.gao.gov/assets/670/661318.pdf

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries

March 4, 2014 Comments off

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries
Source: U.S. Department of Health and Human Services, Office of Inspector General

WHY WE DID THIS STUDY
From 2008-2012, we conducted a series of studies about hospital adverse events, defined as harm resulting from medical care. This work included a Congressionally mandated study to determine a national incidence rate for adverse events in hospitals. As part of this work, we developed methods to identify adverse events, determine the extent to which events are preventable, and measure the cost of events to the Medicare program. This study continues that work by evaluating post-acute care provided in skilled nursing facilities (SNF). SNF post-acute care is intended to help beneficiaries improve health and functioning following a hospitalization and is second only to hospital care among inpatient costs to Medicare. Although various health care stakeholders have in recent years paid substantial attention to patient safety in hospitals, less is known about resident safety in SNFs.

HOW WE DID THIS STUDY
This study estimates the national incidence rate, preventability, and cost of adverse events in SNFs by using a two-stage medical record review to identify events for a sample of 653 Medicare beneficiaries discharged from hospitals to SNFs for post-acute care. Sample beneficiaries had SNF stays of 35 days or less.

WHAT WE FOUND
An estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays. An additional 11 percent of Medicare beneficiaries experienced temporary harm events during their SNF stays. Physician reviewers determined that 59 percent of these adverse events and temporary harm events were clearly or likely preventable. They attributed much of the preventable harm to substandard treatment, inadequate resident monitoring, and failure or delay of necessary care. Over half of the residents who experienced harm returned to a hospital for treatment, with an estimated cost to Medicare of $208 million in August 2011. This equates to $2.8 billion spent on hospital treatment for harm caused in SNFs in FY 2011.

WHAT WE RECOMMEND
Because many of the events that we identified were preventable, our study confirms the need and opportunity for SNFs to significantly reduce the incidence of resident harm events. Therefore, we recommend that AHRQ and CMS raise awareness of nursing home safety and seek to reduce resident harm through methods used to promote hospital safety efforts. This would include collaborating to create and promote a list of potential nursing home events-including events we found that are not commonly associated with SNF care-to help nursing home staff better recognize harm. CMS should also instruct State agency surveyors to review nursing home practices for identifying and reducing adverse events. AHRQ and CMS concurred with our recommendations.

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