Archive for the ‘Medicare and Medicaid’ Category

HHS OIG — Medicare Part B Prescription Drug Dispensing and Supplying Fee Payment Rates Are Considerably Higher Than the Rates Paid by Other Government Programs

September 19, 2014 Comments off

Medicare Part B Prescription Drug Dispensing and Supplying Fee Payment Rates Are Considerably Higher Than the Rates Paid by Other Government Programs
Source: U.S. Department of Health and Human Services, Office of Inspector General

Medicare Part B would have saved millions of dollars in 2011 if dispensing fees for inhalation drugs administered through durable medical equipment and supplying fees for immunosuppressive drugs associated with an organ transplant, oral anticancer chemotherapeutic drugs, and oral antiemetic drugs used as part of an anticancer chemotherapeutic regimen had been aligned with the rates that Part D and State Medicaid programs paid. Part B paid $132.9 million in dispensing and supplying fees. We estimated that if Part B rates had been the same as the average Part D rates, Part B would have paid dispensing and supplying fees of $22 million, a savings of $110.9 million. We also estimated that if Part B rates had been the same as the average State Medicaid program rates, Part B would have paid dispensing and supplying fees of $26.6 million, a savings of $106.3 million.

We recommended that CMS amend current regulations to decrease the Part B payment rates for dispensing and supplying fees to rates similar to those of other payers, such as Part D and Medicaid. CMS did not concur with our recommendation and requested that OIG conduct a study to identify the specific activities involved with dispensing inhalation drugs and supplying oral drugs under Part B and collect information about the actual costs that are directly associated with dispensing these Part B drugs. We maintain that pharmacies are overpaid for dispensing drugs under Part B when compared with what they are paid for dispensing the same drugs under Part D and Medicaid.

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CRS — Health Care Fraud and Abuse Laws Affecting Medicare and Medicaid: An Overview (September 8, 2014)

September 15, 2014 Comments off

Health Care Fraud and Abuse Laws Affecting Medicare and Medicaid: An Overview (PDF)
Source: Congressional Research Service (via Federation of American Scientists)

A number of federal statutes aim to combat fraud and abuse in federally funded health care programs such as Medicare and Medicaid. Using these statutes, the federal government has been able to recover billions of dollars lost due to fraudulent activities. This report provides an overview of some of the more commonly used federal statutes used to fight health care fraud and abuse and discusses some of the changes made to these statutes by the Patient Protection and Affordable Care Act (ACA).

Title XI of the Social Security Act contains Medicare and Medicaid program-related anti-fraud provisions, which impose civil penalties, criminal penalties, as well as exclusions from federal health care programs on persons who engage in certain types of misconduct. ACA amends these administrative sanctions and authorizes the imposition of several new civil monetary penalties and exclusions.

Graduate Medical Education That Meets the Nation’s Health Needs

September 11, 2014 Comments off

Graduate Medical Education That Meets the Nation’s Health Needs
Source: Institute of Medicine

Since the creation of the Medicare and Medicaid programs in 1965, the public has provided tens of billions of dollars to fund graduate medical education (GME), the period of residency and fellowship that is provided to physicians after they receive a medical degree. Although the scale of govern­ment support for physician training far exceeds that for any other profession, there is a striking absence of transparency and accountability in the GME financing system for producing the types of physicians that the nation needs.

The IOM formed an expert committee to conduct an independent review of the governance and financing of the GME system. The 21-member IOM committee concludes that there is an unquestionable imperative to assess and optimize the effectiveness of the public’s investment in GME. In its report, Graduate Medical Education That Meets the Nation’s Health Needs, the committee recommends significant changes to GME financ­ing and governance to address current deficiencies and better shape the phy­sician workforce for the future. The IOM report provides an initial road­map for reforming the Medicare GME payment system and building an infrastructure that can drive more strategic investment in the nation’s physician workforce.

New From the GAO

September 8, 2014 Comments off

New GAO Reports
Source: Government Accountability Office

1. Defense Infrastructure: DOD Needs to Improve Its Efforts to Identify Unutilized and Underutilized Facilities. GAO-14-538, September 8.
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2. Information Security: Agencies Need to Improve Oversight of Contractor Controls. GAO-14-612, August 8.
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3. Personnel Security Clearances: Additional Guidance and Oversight Needed at DHS and DOD to Ensure Consistent Application of Revocation Process. GAO-14-640, September 8.
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4. Medicaid Demonstrations: HHS’s Approval Process for Arkansas’s Medicaid Expansion Waiver Raises Cost Concerns. GAO-14-689R, August 8.

5. Crop Insurance: Considerations in Reducing Federal Premium Subsidies. GAO-14-700, August 8.
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6. Special Operations Forces: DOD’s Report to Congress Generally Addressed the Statutory Requirements but Lacks Detail. GAO-14-820R, September 8.

7. DOD Education Benefits: Action Is Needed To Ensure Evaluations Of Postsecondary Schools Are Useful. GAO-14-855, September 8.
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New From the GAO

September 3, 2014 Comments off

New GAO Reports
Source: Government Accountability Office

1. VA Dialysis Pilot: Documentation of Plans for Concluding the Pilot Needed to Improve Transparency and Accountability. GAO-14-646, September 2.
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2. Medicare Advantage: CMS Should Fully Develop Plans for Encounter Data and Assess Data Quality before Use. GAO-14-571, July 31.
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3. Human Capital: OPM Needs to Improve the Design, Management, and Oversight of the Federal Classification System. GAO-14-677, July 31.
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What is the Result of States Not Expanding Medicaid?

August 29, 2014 Comments off

What is the Result of States Not Expanding Medicaid?
Source: Urban Institute

In states not expanding Medicaid, 6.7 million residents will remain uninsured in 2016 as a result. These states are foregoing $423.6 billion in federal Medicaid funds from 2013 to 2022, lessening economic activity and job growth. Their hospitals are also losing $167.8 billion in Medicaid revenue. Every comprehensive state-level fiscal analysis that we could find concluded that expansion helps state budgets, generating savings and revenues that exceed increased Medicaid costs. Future federal cuts to ACA’s high federal match rate are unlikely. Of more than 100 federal Medicaid cuts since 1980, just one lowered the federal share of Medicaid spending.

Small Geographic Area Variations in Prescription Drug Use

August 18, 2014 Comments off

Small Geographic Area Variations in Prescription Drug Use
Source: Pediatrics

BACKGROUND: Despite the frequency of pediatric prescribing little is known about practice differences across small geographic regions and payer type (Medicaid and commercial).

OBJECTIVE: The goal of this research was to quantify variation in prescription drug use among northern New England children.

METHODS: Northern New England, all-payer administrative data (2007–2010) permitted study of prescriptions for 949 821 children ages 0 to 17 years (1.75 million person-years [PYs]; 54% Medicaid, 46% commercial). Age- and gender adjusted overall and drug group–specific prescription use was quantified according to payer type (Medicaid or commercial) and within payer type across 69 hospital service areas (HSAs). We measured prescription fills per PY (rate) and annual, mean percentage of the population with any drug group–specific fills (prevalence).

RESULTS: Overall mean annual prescriptions per PY were 3.4 (commercial) and 5.5 (Medicaid). Generally, these payer type differences were smaller than HSA-level variation within payer type. HSA-level rates of attention-deficit/hyperactivity disorder drug use (5th–95th percentile) varied twofold in Medicaid and more than twofold in commercially insured children; HSA-level antidepressant use varied more than twofold within each payer type. Antacid use varied threefold across HSAs and was highest in infants where commercial use paradoxically exceeded Medicaid. Prevalence of drug use varied as much as rates across HSAs.

CONCLUSIONS: Prescription use was higher among Medicaid-insured than commercially insured children. Regional variation generally exceeded payer type differences, especially for drugs used in situations of diagnostic and therapeutic uncertainty. Efforts should advance best pediatric prescribing discussions and shared decision-making.


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