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Measuring Coding Intensity in the Medicare Advantage Program

November 13, 2014 Comments off

Measuring Coding Intensity in the Medicare Advantage Program
Source: Centers for Medicare and Medicaid Services (HHS)

Background:
In 2004, Medicare implemented a system of paying Medicare Advantage (MA) plans that gave them greater incentive than fee-for-service (FFS) providers to report diagnoses.

Data:
Risk scores for all Medicare beneficiaries 2004–2013 and Medicare Current Beneficiary Survey (MCBS) data, 2006–2011.

Measures:
Change in average risk score for all enrollees and for stayers (beneficiaries who were in either FFS or MA for two consecutive years). Prevalence rates by Hierarchical Condition Category (HCC).

Results:
Each year the average MA risk score increased faster than the average FFS score. Using the risk adjustment model in place in 2004, the average MA score as a ratio of the average FFS score would have increased from 90% in 2004 to 109% in 2013. Using the model partially implemented in 2014, the ratio would have increased from 88% to 102%. The increase in relative MA scores appears to largely reflect changes in diagnostic coding, not real increases in the morbidity of MA enrollees. In survey-based data for 2006–2011, the MA-FFS ratio of risk scores remained roughly constant at 96%. Intensity of coding varies widely by contract, with some contracts coding very similarly to FFS and others coding much more intensely than the MA average. Underpinning this relative growth in scores is particularly rapid relative growth in a subset of HCCs.

Discussion:
Medicare has taken significant steps to mitigate the effects of coding intensity in MA, including implementing a 3.4% coding intensity adjustment in 2010 and revising the risk adjustment model in 2013 and 2014. Given the continuous relative increase in the average MA risk score, further policy changes will likely be necessary.

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2015 Medicare Part B premiums and deductibles to remain the same as last two years

October 10, 2014 Comments off

2015 Medicare Part B premiums and deductibles to remain the same as last two years
Source: HHS Centers for Medicare and Medicaid Services

Secretary of Health and Human Services Sylvia Burwell announced today that next year’s standard Medicare Part B monthly premium and deductible will remain the same as the last two years. Medicare Part B covers physicians’ services, outpatient hospital services, certain home health services, durable medical equipment, and other items. For the approximately 49 million Americans enrolled in Medicare Part B, premiums and deductibles will remain unchanged in 2015 at $104.90 and $147, respectively. This leaves more of seniors’ cost of living adjustment from Social Security in their pockets.

CMS.gov — Open Payments

October 3, 2014 Comments off

CMS.gov — Open Payments
Source: U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services

Sometimes, doctors and hospitals have financial relationships with health care manufacturing companies. These relationships can include money for research activities, gifts, speaking fees, meals, or travel. The Social Security Act requires CMS to collect information from applicable manufacturers and group purchasing organizations (GPOs) in order to report information about their financial relationships with physicians and hospitals. Open Payments is the federally run program that collects the information about these financial relationships and makes it available to you.

See also: Physician Payment Sunshine Act: A Primer (American Action Forum)

Per Capita Health Spending for Elderly Grows at Lowest Rate among all Age Groups from 2002-2010

June 3, 2014 Comments off

Per Capita Health Spending for Elderly Grows at Lowest Rate among all Age Groups from 2002-2010
Source: U.S. Department of Health and Human Services, Center for Medicare and Medicaid Services

verage annual growth in per capita personal health care spending for the elderly was 4.1 percent from 2002 to 2010, the lowest among any other age groups studied, according to a report by the Centers for Medicare & Medicaid Services’ Office of the Actuary released today and published in the journal Health Affairs.

These estimates are a subset of the annually-issued National Health Expenditure (NHE) data, which measures health care spending in the United States. The report examines aggregate and per-capita health spending by gender and major age groups.

Personal health care costs consist of all the medical goods and services used to treat or prevent a specific disease or condition in a specific person. As such, the estimates of health spending by age and gender reflect the types of goods and services delivered including hospital care, physician and clinical services, retail prescription drugs, and the programs and payers for that care, such as private health insurance, Medicare, Medicaid.

Overall, the authors of the report found that growth in spending among groups over this time period varied, especially during the recent recession. For instance, in 2008–10 the largest difference in average spending growth between males and females was for the working-age group (19-64). In this period per capita spending growth for this group was 4.0 percent for males but 2.6 percent for females. A 3.7 percent decline in the birth rate in the period may be one of the causes: Growth in spending for females ages 19–44 slowed as they spent relatively less on maternity care.

However, the impact of the recession on the elderly is less clear. Per capita spending growth for this group in 2008–10 averaged just 2.4 percent annually, which was lower than growth for the other age groups. Slower Medicare spending and continued slow growth in spending for nursing care facilities and continuing care retirement communities contributed to the low rate of growth. Also, private health insurance spending per enrollee for those ages sixty-five and older grew slowly, at 3.0 percent annually over the period—the slowest growth rate of private health insurance among the major age groups. Out-of pocket spending per person for the elderly declined 0.4 percent annually over this period.

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.

CMS Finalizes Physician Payment Rates for 2014

December 4, 2013 Comments off

CMS Finalizes Physician Payment Rates for 2014
Source: U.S. Department of Health and Human Services (Centers for Medicare and Medicaid Services)

In a rule issued today, the Centers for Medicare & Medicaid Services (CMS) finalized payment rates and policies for 2014, including a major proposal to support care management outside the routine office interaction as well as other policies to promote high quality care and efficiency in Medicare. CMS’ care coordination policy is a milestone, and demonstrates Medicare’s recognition of the importance of care that occurs outside of a face-to-face visit for a wide range of beneficiaries beginning in 2015. The final rule sets payment rates for physicians and non-physician practitioners paid under the Medicare Physician Fee Schedule for 2014 and addresses the policies included in the proposed rule issued in July. CMS projects that total payments under the fee schedule in 2014 will be approximately $87 billion.

As part of CMS’ continuing effort to recognize the critical role primary care plays in providing care to beneficiaries with multiple chronic conditions, beginning in 2015, the agency is establishing separate payments for managing a patient’s care outside of a face-to-face visit for practices equipped to provide these services.

Observations Noted During the OIG Review of CMS’s Implementation of the Health Insurance Exchange-Data Services Hub

August 5, 2013 Comments off

Observations Noted During the OIG Review of CMS’s Implementation of the Health Insurance Exchange-Data Services Hub
Source: U.S. Department of Health and Human Services, Office of Inspector General

This memorandum report provides the results of our review of the Centers for Medicare & Medicaid Services’ (CMS) implementation of the Data Services Hub (Hub), which is intended to support Health insurance exchanges, from a security perspective. To determine the status of the implementation of the Hub, we assessed the information technology security controls that CMS is implementing for the Hub, adequacy of the testing activities being performed during its development, and the coordination between CMS and Federal and State agencies during the development of the Hub.

CMS is working with very tight deadlines to ensure that security measures for the Hub are assessed, tested, and implemented by the expected initial open enrollment date for health insurance exchanges of October 1, 2013. If there are additional delays in completing the security assessment and testing, CMS may have limited information on the security risks and controls before the exchanges open.

Health insurance exchanges are State-based competitive marketplaces where individuals and small businesses will be able to purchase private health insurance. The Hub will help facilitate the access of data by exchanges; enable verification of coverage eligibility; provide a central point for the Internal Revenue Service when it asks for coverage information; provide data for oversight of the exchanges; provide data for paying insurers; and provide data for use in Web portals for consumers.

CMS stated that it is confident that the Hub will be operationally secure before October 1, 2013.

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