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May 25, 2004
Vol. 1, No. 15
Weekly news and analysis
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| MEDICARE MURMURS |
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Medicare Advantage plans receive more per enrollee
In 2004, private Medicare plans will be paid 8.4% more per enrollee on average than fee-for-service costs, according to a new study by the Commonwealth Fund of New York City. These extra payments to Medicare Advantage plans, formerly called Medicare+Choice, average $552 per plan enrollee-a total of $2.75 billion overall-the Fund reports. The Medicare-reform law paved the way for these increases this year, though the legislation's long-term goal is to create competition among plans and Medicare to help drive down costs, says Commonwealth Fund researcher Brian Biles.
Compiled from staff reports
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| LETTERS TO THE EDITOR |
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Send letters to bcote@hcpro.com. Include tips, ideas, questions, and problems related to Medicare reform. The editors reserve the right to edit letters for clarity. |
| DATEBOOK |
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December 2004-Expect the Office of Inspector General to report to Congress by December on existing End Stage Renal Drug billing codes and their use.
July 1-Hospitals failing to comply with bloodborne pathogen standards are subject to civil money penalities from OSHA. Hospitals must be in compliance this summer. |
© 2004 HCPro, Inc. |
Show me the right cost report
Fifteen Missouri hospitals did not properly record their refund of provider tax expenses on their Medicare cost reports, according to the results of an Office of Inspector General audit announced May 21. Four of those hospitals also made the mistake of including donations they made to the Missouri Hospital Association that aren't allowed under Medicare regulations. These problems occurred because the hospitals did not follow Medicare regulations on claiming provider tax refunds, a CMS spokesperson said. The fiscal intermediary (FI) for the hospitals, when settling cost reports, also inconsistently applied Medicare rules and regulations relating to provider tax refunds and unallowable expenses. As a result, the hospitals received $8.4 million in excess Medicare reimbursement. CMS is expected to instruct FIs to recover the excess reimbursements from the hospitals.
CMS to check discount card sponsor activity
CMS will conduct spot checks on the companies sanctioned to offer the Medicare prescription-drug discount cards to make sure they follow federal guidelines. "We need to assume that there's going to be people out there who will, unfortunately, try to take advantage of every effort we make to help seniors, and we're going to do all we can to prevent it," CMS Administrator Mark McClellan said during a press conference this week. "We've not seen any evidence of widespread fraud so far, and we intend to keep it that way," McClellan added. Companies that sponsor the cards cannot solicit customers through cold calls or door-to-door visits, he said. McClellan urged anyone who receives such offers to contact either CMS or local authorities. For more information, see "Drug Payment Reform" below.
| Exec Corner: CMS clears up emergency cart rumor |
There's some confusion spreading about the need to lock emergency drug and supply crash carts behind closed doors after clinic hours. "It's a rumor," says Donald McLeod, MA, OE, a spokesman for the Centers for Medicare & Medicaid Services (CMS).
You don't need to keep these carts behind closed doors. "Keep them where patients are," says McLeod, as long as you have medical staff (e.g., nurses, etc) nearby. The cart must have a plastic safety lock that personnel can open when necessary, but hospitals do not need to store the carts, because that, McLeod said, would make it difficult for staff to access them in a rush. "We don't want to hinder patient care."
McLeod added that if your clinic is closed overnight and no medical staff is present, it is appropriate to lock the carts away safely. His tip: It's a balance, just don't leave them unattended.
The CMS and the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) have both expressed concern that people can steal syringes and drugs from unattended carts. The JCAHO standards do not require hospitals to store carts, either. Emergency carts on clinics and inpatient floors store all the emergency drugs and supplies in case of cardiopulmonary arrest.
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Tip for pricing drugs in reform era
"Pricing a product 10% lower than the market leader does not count against anyone's budget. However, for a product with sales potential of $500 million per year, that 10% actually costs $50 million in foregone revenue and profit. If, instead of taking the discount, your firm spends half of that amount ($25 million) on additional promotion, the product would realize more sales."
Source: E.M. Mick Kolassa, PhD, MBA, associate professor of pharmacy administration, University of Mississippi, "A World Without AWP," January 15, 2004, Washington, DC
CMS takes steps to cut down on drug card fraud
Reports on fraud related to the Medicare drug benefit prescription cards--even before the information was released to beneficiaries a month ago--has activated the Centers for Medicare and Medicaid Service's Office of Program Integrity to new steps to stop it, said Kimberly Brandt, the office's acting director, at the May 16 Medical Group Management Association's (MGMA) legislative and compliance issues meeting in Washington.
Since the beginning of the month, 23 cases have been reported to her office and forwarded to law enforcement authorities. In most of the cases-including three cases where money from individual's bank accounts were stolen-"we've already taken action and have had people prosecuted and put in jail," Brandt said.
As one step, the office has hired a "safeguard contractor" who will be monitoring the prescription drug card sponsors "to determine whether or not they're being good actors"-now and in the future when the prescription drug benefit goes into effect in 2006. Also, the office has been working not only with HHS Office of Inspector General and the Federal Bureau of Investigation, but with officials in Canada and several other countries that have nationalized prescription drug systems "so that we can prevent similar instances [of fraud] from occurring with the Americans when we go live in 2006," she said.
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Officials hear suggestions on comparative effectiveness
To meet requirements of Section 1013 of the Medicare Prescription Drug Improvement and Modernization Act of 2003-which authorizes the Department of Health and Human Services (HHS) to support research on outcomes, comparative clinical effectiveness, and appropriateness of health care items, services, and pharmaceuticals for use by the Centers for Medicare & Medicaid Services (CMS)-HHS agency heads held a May 21 listening session in Washington, DC, to obtain public input on how the department should proceed.
The law requires an initial priority list to be completed by June; the deadline for completing the original research is December 2005-just a month before the new Medicare drug regulation takes effect.
"Important questions remain about the best clinical options for treatment of specific conditions and where additional evidence would help doctors and patients make more informed decisions about their healthcare choices and the use of potentially important medical technology," said CMS Administrator Mark McClellan, MD, PhD, during the session. "[These are] decisions that could have large consequences for health outcomes and the cost of the Medicare program."
Payers not required to use data
Section 1013 will lead to collaboration between the Agency for Healthcare Research Quality (AHRQ) and CMS, but payers won't be required to use the data that the two groups uncover. "[Section 1013] has the potential to move us to a whole new level," said AHRQ Administrator Carolyn Clancy, MD. AHRQ will work with CMS to evaluate the "comparative effectiveness" of different treatments and clinical approaches. "Sometimes this information isn't used because it doesn't exist," she said. "Other times, the findings aren't organized in a way that's understandable and accessible."
Clancy emphasized at the session that section 1013 will not be used to mandate national clinical practice and quality health care standards, nor will it be used to deny coverage of certain pharmaceuticals or services in the federal programs. Although it will be used to help Medicare, Medicaid, and the State Children's Health Insurance Program deliver better treatment outcomes, payers will not be required to use the data.
Many of the proposals made during the listening session--by groups including AARP, Consumers Union, the National Business Group on Health, the Medical Technology and Practice Patterns Institute, and the Blue Cross-Blue Shield Association--focused on comparing the effectiveness of prescription drugs. However, one group, the Pharmaceutical Research and Manufacturers of America, urged the panel to consider a broader approach that focuses on more quality issues "rather than cost cuts."
Editor's note: Interested parties can continue to contribute suggestions on clinical effectiveness topics to federal officials by using the Food and Drug Administration's docket system, which can be accessed through the Section 1013 portion of www.Medicare.gov.
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Reported quality data misleading
Of the almost 3,500 hospitals registered to publicly report quality data under the National Voluntary Hospital Reporting initiative, fewer than one-third (1,032) of the hospitals in this group meet the Medicare-reform submission standards.
Hospitals have until July 1 to submit data to their quality improvement organizations (QIO). Data must be reported in the three disease categories: heart attack (acute myocardial infarction), heart failure, and pneumonia cases. Hospitals with incomplete submissions will have a 30-day grace period. Missing the deadline means a hospital's Medicare payments will drop by 0.4% in 2005.
Two warnings from a CMS staffer: Register with your QIO by June 1 and make sure your data cover all patients in the three disease areas, not just Medicare patients. CMS will check to ensure that data are in the proper format.
Note: If you need help reporting this data to meet the standards, or have any confusion on how to do it, e-mail bcote@hcpro.com with your contact information.
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McClellan moves up e-prescribing goal to 2006-07
During the May 17 Medical Group Management Association's legislative and compliance issues meeting in Washington, DC, Centers for Medicare & Medicaid Services (CMS) Administrator Mark McClellan, MD, PhD, said CMS wants more input from physicians as it works to implement Medicare-reform provisions-and to make sure Medicare is more responsive to their needs than it has been in the past. Here are a few examples:
1. E-prescribing
In conjunction with the Medicare drug benefit in 2006, McClellan said CMS is pushing ahead on completing standards and "developing better incentives" for the widespread use of electronic prescribing. According the new Medicare law, widespread e-prescribing is scheduled for 2009. "But I think we can do much better than that," he said. CMS is "taking steps to identify what works, to identify whether there are more incentives that we can create towards the adoption of e-prescribing programs, and to look at the programs out there that are successful now and build on them," he said.
McClellan estimates CMS will implement widespread e-prescribing "substantially" soon, but we're going to need your help in getting there," McClellan told MGMA meeting attendees. "I want to know you'll be hearing a lot from us at CMS-from me in particular-to make sure that you have what you need to help your patients stay well-informed about what is coming in medical technology and our healthcare system and their Medicare benefits-and how to get the most out of them."
2. Physician input
McClellan noted that the Medicare-reform law calls for greater improvements in claims-processing services over the next several years. "As you all know, we're moving toward a new system of competitive bidding for our contracting services. Our contractors for the first time will have to meet some major performance measures for the accuracy and quality for processing services-or they will be out of the Medicare program," he said.
"We want to work with [physicians and physician groups] on implementing these fundamental contractor reforms effectively to make sure we've got the right-and best-performance measures in place, and a good system for monitoring how well we're doing," McClellan said.
3. Contractor quality
CMS also wants to make sure that the Medicare contractors who are rewarded are the "ones who are providing best services" and that as many physicians as possible get the "benefit of these high-quality services," he said. "This is a fundamentally more competitive system-a fundamentally more responsive system-than we've had in the past."
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Bryan Cote
Executive Editor
E-mail address: bcote@hcpro.com |
