Data transparency at CMS

From the Health Affairs blog:

Over time it has become very clear that health care today relies on sharing data to drive improvements in access and care delivery as well as control costs. The Centers for Medicare and Medicaid Services (CMS) has embraced the need for greater data transparency while recognizing the importance of appropriately protecting personally identifiable information (PII).

Five years ago, CMS began to actively explore opportunities to provide new avenues for accessing data in order to make data available to a broader group of users. We are proud to say that today we are routinely and safely sharing data to support the transformation of the delivery system

Sharing data with providers. We are developing a broader strategy for providing more data to providers for performance measurement and quality improvement. For example, CMS is:

    • helping to promote efficiency in performance measurement through the qualified entity (QE) program. This program creates a structure through which providers can receive a single, actionable report covering all or most of their practice. QEs combine Medicare claims data from CMS with claims data from other payers to create comprehensive reports on the performance of hospitals, physicians, and other health care providers.
    • providing Accountable Care Organizations (ACOs) with monthly claims feeds covering the almost 3 million beneficiaries being cared for by physicians participating in the ACOs. The monthly feeds include care the beneficiary receives from both providers participating in the ACO and those that do not participate. These data permit the ACO to coordinate care for beneficiaries and provide true patient-centered care in a fee-for-service system.
    • working to improve the performance reports that providers currently receive from CMS to ensure that they are as meaningful as possible. An example of such a report is the Quality and Resource Use Reports released to physicians and physician groups.
    • developing a strategy for providing more data to more providers for performance measurement and quality improvement as required by the American Taxpayer Relief Act of 2012.

Read the complete post here.

Variation in Health Care Spending: Target Decision Making, Not Geography

New from the National Academies Press:

Health care in the United States is more expensive than in other developed countries, costing $2.7 trillion in 2011, or 17.9 percent of the national gross domestic product. Increasing costs strain budgets at all levels of government and threaten the solvency of Medicare, the nation s largest health insurer. At the same time, despite advances in biomedical science, medicine, and public health, health care quality remains inconsistent. In fact, underuse, misuse, and overuse of various services often put patients in danger.

Many efforts to improve this situation are focused on Medicare, which mainly pays practitioners on a fee-for-service basis and hospitals on a diagnoses-related group basis, which is a fee for a group of services related to a particular diagnosis. Research has long shown that Medicare spending varies greatly in different regions of the country even when expenditures are adjusted for variation in the costs of doing business, meaning that certain regions have much higher volume and/or intensity of services than others. Further, regions that deliver more services do not appear to achieve better health outcomes than those that deliver less.

Variation in Health Care Spending investigates geographic variation in health care spending and quality for Medicare beneficiaries as well as other populations, and analyzes Medicare payment policies that could encourage high-value care. This report concludes that regional differences in Medicare and commercial health care spending and use are real and persist over time. Furthermore, there is much variation within geographic areas, no matter how broadly or narrowly these areas are defined. The report recommends against adoption of a geographically based value index for Medicare payments, because the majority of health care decisions are made at the provider or health care organization level, not by geographic units. Rather, to promote high value services from all providers, Medicare and Medicaid Services should continue to test payment reforms that offer incentives to providers to share clinical data, coordinate patient care, and assume some financial risk for the care of their patients.

Order a prepublication copy or read it for free on the National Academies Press web site.

Promoting cooperative federalism through state shared savings

From the Health Affairs blog:

 A new commentary, being released today as a Web First by Health Affairs, discusses the concept of “cooperative federalism” in light of the Affordable Care Act. It proposes an optional shared savings program between the states and the federal government as a response to concerns that there may be increased federal control over implementation of the health reform laws at the state level because state decisions will determine the level of federal spending. For example, state decisions regarding Medicaid benefits, payment levels, and the use of managed care, and state exchange policies on rate review, qualifying health plans, and defining essential health benefits, would all directly affect health costs. In this proposed program, the federal government would share with the states any federal savings relative to expected expenditures on state-administered health programs; it would not operate through waivers; and the details of the program would develop through open rule making.

In the author’s opinion, relations between state governments and Washington have been in a state of “uneasy truce” in which the federal government has been accommodating by never exercising its full authority, and the states have put to maximum use the flexibility offered, particularly in tailoring the Medicaid program to their needs. However, this truce, the author claims, has been threatened by the expanded scope of federal control in the Affordable Care Act and fears that the federal government will show heavy handedness as implementation of the law proceeds. Proposing a new shared savings program, the author says, “In this program, the federal government would share with the states any savings in comparison to what the federal government expects it would have paid for programs that have federal financial participation.” The author would tie shared savings to performance standards and suggests that the shared savings program be based on a predetermined formula, not negotiated one state at a time. This program, concludes the author, “offers a path forward that would align states and the federal government in their quest for better performance while limiting the risk to program beneficiaries.”

Feds say “no” to partial Medicaid expansion

From NPR’s Shots blog:

The Affordable Care Act, as passed by Congress in 2010, assumed that every low income person would have access to health insurance starting in 2014.

That’s when about 17 million Americans — mostly unmarried healthy adults with incomes up to 133 percent of poverty, or about $15,000 a year — would gain access to Medicaid.

The program currently covers parents, children, the elderly and those with disabilities. Because adding more people to the program could overburden state budgets, the federal government would pay 100 percent of the additional cost for the first three years, phasing down to 90 percent.

But the Supreme Court upset this plan last summer when it decided the Medicaid expansion should be optional. Republican governors started to ask if they could expand Medicaid just somewhat, but still collect the additional federal funding for it.

After several months of consideration, the Obama Administration delivered its decision Monday, as part of a series of questions and answers for states about Medicaid expansions and the set up health care exchanges.

Read the complete post and listen to the story on the blog.

Sharp cuts in dental coverage for adults on Medicaid

From the New York Times:

Banned from tightening Medicaid eligibility in recent years, many states have instead slashed optional benefits for millions of poor adults in the program.

Teeth have suffered disproportionately.Republican- and Democratic-controlled states alike have reduced or largely eliminated dental coverage for adults on Medicaid, the shared state and federal health insurance program for poor people. The situation is not likely to improve under President Obama’s health care overhaul: it requires dental coverage for children only.

Illinois became the latest state to drastically cut dental benefits last month, when Gov. Pat Quinn, a Democrat, cut $1.6 billion out of its $15 billion Medicaid budget, reducing adult dental coverage to emergency tooth extractions. The state, whose Medicaid program was considered among the most generous, also cut vision benefits, eliminated chiropractic and podiatry coverage and started requiring co-payments for drugs.

In about half the states, Medicaid now covers dental care only for pain relief and emergencies, according to a recent report by the Kaiser Commission on Medicaid and the Uninsured, a national health research group. Other states cover preventive exams and cleanings but not restorative services, like fillings and root canals.

Read the complete story here.

Healthcare Innovations Summit – Recap now available

On January 26, 2012, health delivery systems, physicians, innovators, policymakers, academics and venture capitalists gathered at the Care Innovations Summit in Washington, DC.

More than 1,200 individuals participated in person and an additional 3,000 joined online. Hosted by the Centers for Medicare & Medicaid Services (CMS), the West Wireless Health Institute (WWHI), and Health Affairs, this event showcased care delivery and payment solutions already working in the marketplace, catalyzing the dialogue for applying and expanding successful solutions to lower the cost of health care.

The Summit recap can be found here.

Continue the conversationby emailing or tweeting  updates: or #cisummit. Check back on for updated content and videos.

New Study Suggests Improvements For Estimating Who Is Eligible For Health Insurance Exchange Subsidies

From Health Affairs:

State governments are preparing for the advent of individual health insurance exchanges in 2014, and for the projected seventeen million Americans who meet certain income eligibility criteria but are not eligible for Medicaid or an affordable employer-sponsored plan who will be awarded federal tax credits to offset the cost of purchasing coverage through an exchange.

The Congressional Budget Office has estimated that just less than half of the $1.8 trillion in gross federal outlays for coverage provisions under the Affordable Care Act will be used for this purpose. Eligibility for advance access to this credit is determined by projecting a household’s modified adjusted gross income at the time a member of the household applies. A new study, released as a Web First by Health Affairs, found that this method of determining eligibility could result in many false positives and false negatives, causing those eligible for the subsidies to be refused early access to them and causing some households that are initially determined eligible to be required to pay back the subsidies they receive. In a simulation, the study determined that by augmenting data from prior tax returns with six months of current income to determine eligibility for Medicaid and the exchanges, the number of people incorrectly deemed ineligible with allowances for change decreased by more than 40 percent.

For his analysis, the author used a longitudinal microsimulation model of the Affordable Care Act, factoring in income, employment, family composition, and taxes from the 2001 Survey of Income and Program Participation. Additionally, the simulation results showed that advance subsidies tended to overpay by $208 annually on average, but that there will be meaningful differences between advances and final subsidies for many low-income households.

Adopting an eligibility determination policy that is transparent, consistent across Medicaid and the exchanges, and generous in allowing applicants to claim a change in circumstances will…be critical,” concluded the author. “Policy makers should consider statutory and regulatory changes that further align Medicaid and the exchanges under a single income standard.”

Read the article here.

In state news – Mich. Medicaid Director: “a struggle” to meet deadlines if law upheld

From Kaiser Health News:

KHN’s Mary Agnes Carey talks to Michigan Medicaid Director Steve Fitton about how it will be a “struggle” for his state to be ready to implement the health law on schedule if the Supreme Court upholds the measure. But he’s confident that Michigan can handle the expected new enrollees in Medicaid. Fitton says Michigan officials want to move beneficiaries with both Medicare and Medicaid into managed care if the law is upheld.

Read an edited transcript of the interview or view the video here.


Report offers glimpse of health law’s Impact on Washington State

From Kaiser Health News, KUOW, and NPR:

Washington State Insurance Commissioner Mike Kreidler is weighing in on the fate of the Affordable Care Act with a report released this week about what’s at stake for Washingtonians if the law is overturned by the Supreme Court.

“There’s so much confusion and misunderstanding out there,” says Kreidler, a Democrat. “This is kind of a heads-up, an early warning that depending on what the court ends up doing, this is what’s in jeopardy for Washingtonians.”

The report finds that:

  • The uninsured in Washington have grown from 12 percent of the population in 2004 to a projected 16 percent in 2013; from about 700,000 to 1.1 million in raw numbers.
  • Some 328,000 currently uninsured Washingtonians would gain coverage under the ACA’s Medicaid expansion.
  • Another 477,400 uninsured residents of the state would qualify for subsidies to buy insurance in the exchanges.

Read the complete post here.