$4B in Medicare payment recoveries but negative ROI? Not!

Report shows $6.7 billion in improper Medicare payments 

WASHINGTON — Medicare paid out $6.7 billion in 2010 for health care visits that were improperly coded or lacked documentation, a report released Thursday found.

That's 21% of Medicare's total budget for diagnostic and assessment visits, according to the Department of Health and Human Services inspector general.

Check out this story on USATODAY.com: http://www.usatoday.com/story/news/nation/2014/05/29/new-inspection-reveals-billions-in-improper-medicare-payments/9682353/

Let's see:  $4B in recoveries in 2013 through CMS Recovery Audit Contractors (RACs) and the new HHS Secretary Sylvia Mathews Burwell saying "she would work toward making sure errors and fraud are caught before payments are made to provider".  

That policy statement may lead to a shift from post-payment recovery audits to pre-payment documentation review by Medicare Administrative Contractors (MACs), but the current administration smells blood (thy name is money) in the form of fraud, and we can all be sure that the recovery efforts will only increase, in whatever form they take.

New funding gives states and innovators tools and flexibility to implement delivery system reform

The State Innovation Model initiative may be a facilitator for States to investigate new reimbursement mechanisms that not only pay for quality but also address the issue of supply and demand, as is considered in the patented methodology presented by Supply Efficiency Scoringsm.


Here is the text of the CMS press release:
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Today, Department of Health and Human Services announced new delivery system reform efforts made possible by the Affordable Care Act that offer states and innovators tools and flexibility to transform health care.

Under the Health Care Innovation Awards program, twelve prospective recipients may receive as much as $110 million in combined funding, ranging from an expected $2 million to $18 million over a three-year period, to test innovative models designed to deliver better care outcomes and lower costs. Examples include projects to provide better care for dementia patients, improve coordination between specialists and primary care physicians, and to improve cardiac care. 

Round two of the Health Care Innovation Awards program focuses on four priority areas: rapidly reducing costs for patients with Medicare and Medicaid; improving care for populations with specialized needs; testing improved financial and clinical models for specific types of providers, including specialists; and linking clinical care delivery to preventive and population health. The twelve prospective recipients will test models in all four categories and spanning 13 states. Additional prospective recipients will be announced in the coming months.

Also today, HHS announced up to $730 million in available funding as part of the State Innovation Model initiative to help states design and test improvements to their public and private health care payment and delivery systems. Project goals are to improve health, improve care, and decrease costs for consumers, including Medicare, Medicaid, and Children's Health Insurance Program (CHIP) beneficiaries. 

The twelve innovative projects announced today represent the first batch of prospective recipients for round two of Health Care Innovation Awards program funding. In 2012, 107 organizations located in urban and rural areas, all 50 states, the District of Columbia and Puerto Rico received awards through round one of the initiative.   

As part of the State Innovation Model initiative, states, territories and the District of Columbia can apply for either a Model Test award to assist in implementation or a Model Design award to develop or enhance a comprehensive State Health Care Innovation Plan. Up to 12 states will be chosen for state sponsored Model Testing awards ($700 million available) and up to 15 states will be chosen for state-sponsored Model Design work ($30 million available).

For more information about the Health Care Innovation Awards program prospective recipients announced today, go to: innovation.cms.gov/initiatives/Health-Care-Innovation-Awards/Round-2.

Currently, there 25 states are participating in the State Innovation Models initiative. For more information on the initiative, including the Funding Opportunity Announcement, please visit: innovation.cms.gov/initiatives/state-innovations.

To learn more about other innovative models being tested by the CMS Innovation Center, please visit: innovation.cms.gov.

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Click here to see which states are currently participating in the program and at what stage.  I believe significant opportunity exists to impact the growth of health care costs without suppressing care delivery or outcomes.

CMS Press Release on new Prior Authorization use cases for esMD

2014-05-22 - Centers for Medicare & Medicaid Services


The esMD (electronic submission of medical documentation) net is growing broader.  This proposed rule is much more than incremental savings to Medicare.  It will be another policy driver for health information exchange as envisioned by the esMD project.  

Health Information Handlers will need to evaluate how (or if) to incorporate these use cases into their workflows.  This is especially true for the few HIHs that are actual exchange platforms, like MEA (Medical Electronic Attachment).

Visualizing Health Policy: Public Opinion at the end of the First Open Enrollment Period

Repost of an interesting infographic from Kaiser Family Foundation:

http://kff.org/infographic/visualizing-health-policy-public-opinion-at-the-end-of-the-first-open-enrollment-period/

How IT is Driving Changes in Community-Based Healthcare

CLICK HERE to read article on how IT is impacting community-based healthcare.


I would add the important function of patient data enhancement at time of eligibility verification at the point of care, such as is accomplished by RxManagement's MedCheck service (see an example MEDCHECK REPORT).


An example of another technology that enhances healthcare delivery is health information exchange between healthcare stakeholders.  Of course, over public and private 250 HIEs  are struggling to develop pervasive and ubiquitous solutions, but they must be complimented by existing transitional technology, such as unstructured (i.e., human-readable) health information exchange, as is conducted by the nation's second largest Health Information Handler for CMS, Medical Electronic Attachment.  MEA provides a transitional capability to request and exchange health information between providers and managed care organizations using methods and information that is available today.


Health IT is helping to inch us closer to truly integrated delivery to the benefit of all, especially the patient.

New HHS data show quality improvements saved 15,000 lives and $4 billion in health spending

Read HHS press release here

This is a win and good trend for institutional quality and the associated reduction of hospital readmissions for all reasons.  

Now, the question in my mind is how to quantify the other side of the quality spectrum; namely, the practical meaning of increases in health plan quality scores represented by HEDIS and STARS.  

In other words, are we measuring the availability of data or actual quality of healthcare delivery?

Top Health Plans for 2012-2103: NCQA's Health Insurance Plan Rankings

As HEDIS results for the 2013 measurement year are submitted and the results compiled, here is a reminder of the top private, Medicare and Medicaid health plans for the prior measurement year.

Top 20 Private Health Insurance Plans

NCQA evaluated over 538 private health plans and ranked 474 of those based on clinical performance, member satisfaction and NCQA Accreditation. To be eligible for rankings, health plans must authorize public release of their performance information and submit enough data for statistically valid analysis. NCQA’s Health Insurance Plan Rankings 2012-2013 used NCQA’s established rankings methodology, which has been used and widely recognized since 2005. The NCQA Accreditation status in these rankings is as of June 30, 2012. Please click here for the plans' most current Accreditation status.

Click here for a summary list of all private health insurance plan rankings.
Click here for the detailed ranking list of all private health insurance plans.  

1.   Harvard Pilgrim Health Care – HMO/POS (MA, ME)

2.   Tufts Associated Health Maintenance Organization – HMO/POS (MA)

3.   Capital Health Plan – HMO (FL)

4.   Tufts Benefit Administrators – PPO (MA, RI)

5.    Harvard Pilgrim Health Care – PPO (MA)

6.    Kaiser Foundation Health Plan of Colorado – HMO (CO)

7.    Harvard Pilgrim Health Care of New England – HMO/POS (NH)

8.    Kaiser Foundation Health Plan of Northern California – HMO (CA)

9.    Group Health Cooperative of South Central Wisconsin – HMO (WI)

10.  Kaiser Foundation Health Plan of Southern California – HMO (CA)

11.  Health New England – HMO/POS (MA)

12.  Geisinger Health Plan – HMO/POS (PA)

13.  Kaiser Foundation Health Plan of the Northwest – HMO (OR, WA)

14.  Blue Cross and Blue Shield of Massachusetts HMO Blue – HMO/POS (MA)

15.  Kaiser Foundation Health Plan of the Mid-Atlantic States – HMO (DC, MD, VA)

16.  UPMC Benefit Management Services – HMO/POS (PA)
16.  UPMC Health Plan – HMO/POS (PA)
18.  Grand Valley Health Plan – HMO (MI)
19.  Kaiser Foundation Health Plan - Hawaii – HMO (HI)
20.  Capital District Physicians' Healthcare Network (Self-Funded) – PPO (NY)
20.  CDPHP Universal Benefits – PPO (NY)

Top 10 Medicare Health Insurance Plans

NCQA evaluated over 465 Medicare health plans and ranked 395 of those based on clinical performance, member satisfaction and NCQA Accreditation. To be eligible for rankings, health plans must authorize public release of their performance information and submit enough data for statistically valid analysis. NCQA’s Health Insurance Plan Rankings 2012-2013 used NCQA’s established rankings methodology, which has been used and widely recognized since 2005. The NCQA Accreditation status in these rankings is as of June 30, 2012. Please click here for the plans' most current Accreditation status.

1.   Kaiser Foundation Health Plan of Southern California — HMO  (CA)
2.   Kaiser Foundation Health Plan of Colorado — HMO (CO)
3.   Kaiser Foundation Health Plan of Northern California — HMO (CA)
4.   Capital Health Plan — HMO (FL)
5.   Kaiser Foundation Health Plan of the Northwest — HMO (OR, WA)
6.   Geisinger Health Plan — HMO (PA)
7.   Kaiser Foundation Health Plan - Hawaii — HMO (HI)
8.   Fallon Community Health Plan — HMO (MA)
9.   Group Health Cooperative — HMO (WA)
10. Group Health Plan — HMO (MN, WI)

Click here a list of all Medicare health insurance plan rankings.
Click here the detailed ranking list of all Medicare health insurance plans.

Top 10 Medicaid Health Insurance Plans

NCQA evaluated over 227 Medicaid health plans and ranked 115 of those based on clinical performance, member satisfaction and NCQA Accreditation. To be eligible for rankings, health plans must authorize public release of their performance information and submit enough data for statistically valid analysis. NCQA’s Health Insurance Plan Rankings 2012-2013 used NCQA’s established rankings methodology, which has been used and widely recognized since 2005. The NCQA Accreditation status in these rankings is as of June 30, 2012. Please click here for the plans' most current Accreditation status.

1.   Fallon Community Health Plan — HMO (MA)
2.   Kaiser Foundation Health Plan - Hawaii — HMO (HI)
3.   Network Health — HMO (MA)
4.   Blue Cross Complete of Michigan — HMO (MI)
5.   Neighborhood Health Plan of Rhode Island — HMO (RI)
6.   Neighborhood Health Plan — HMO (MA)
7.   Priority Health — HMO (MI)
8.   UPMC For You — HMO (PA)
9.   Boston Medical Center HealthNet Plan — HMO (MA)
10. Security Health Plan of Wisconsin — HMO (WI)

Click here a list of all Medicaid health insurance plan rankings.
Click here the detailed ranking list of all Medicaid health insurance plans.

© Copyright 2012 NCQA. All Rights Reserved.

Sources: http://www.ncqa.org/Directories/HealthPlans/HealthInsurancePlanRankings/PrivateHealthPlanRankings20122013.aspx

http://www.ncqa.org/Directories/HealthPlans/HealthInsurancePlanRankings/HealthInsurancePlanRankings201213/2012MedicaidandMedicareHealthPlanRankings.aspx

Disruptive Idea of the Day

What if reimbursement for diagnostic procedures was tied to the availability of diagnostic technology in a given market?  Might we be able to slow the increase in healthcare costs without interrupting needed care and encourage investment in under served regions?

What this press release presaged, now has become a reality with the awarding of a patent for Supply Efficiency Scoring, a new way to think about healthcare reimbursement.