CMS issues bulletin regarding the Navigator program and the upcoming 2018 Open Enrollment Period

CMS MEDIA ADVISORY  FOR IMMEDIATE RELEASE August 31, 2017 Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries CMS issues bulletin regarding the Navigator program and the upcoming 2018 Open Enrollment Period The Centers for Medicare & Medicaid Services (CMS) today issued a bulletin that outlines policies related to the Patient Protection and Affordable Care Act (PPACA) Navigator program and enrollment education for the upcoming open enrollment period.  To read the bulletin, visit: https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/Downloads/Policies-Related-Navigator-Program-Enrollment-Education-8-31-2017pdf.pdf ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress

CMS Helping Texas and Louisiana with Hurricane Harvey Recovery

MLN Connects contains important news, announcements, and updates for health care professionals. Special Edition – Thursday, August 31, 2017

CMS Helping Texas and Louisiana with Hurricane Harvey Recovery Hurricane Harvey and Medicare Disaster Related Texas Claims MLN Matters Article — New Tropical Storm Harvey and Medicare Disaster Related Louisiana Claims MLN Matters Article — New CMS Helping Texas and Louisiana with Hurricane Harvey Recovery On August 30, 2017, the Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma announced the efforts that are underway to support Texas and Louisiana in response to Hurricane Harvey. Earlier this week, Health and Human Services Secretary Tom Price, M.D., declared public health emergencies in both States. Actions include temporarily waiving or modifying certain Medicare, Medicaid and Children’s Health Insurance Program (CHIP) requirements to provide immediate relief to those affected by the hurricane and resulting floods. “In light of the natural disaster still unfolding in Texas and Louisiana, CMS is committed to acting as quickly and effectively as possible so the States can continue to ensure the vital health care needs of our most vulnerable beneficiaries are not interrupted,” said CMS Administrator Seema Verma. “CMS is in constant communication with officials in Texas and Louisiana to be sure we are doing all we can to support those in the path of this historic and devastating storm.” CMS and the U.S. Department of Health and Human Services (HHS) are working in close coordination with the Kidney Community Emergency Response (KCER) Network and the States of Texas and Louisiana to ensure that beneficiaries have access to facilities to provide their treatments. As the CMS response continues, other efforts include, supporting Texas and Louisiana in arranging Special Purpose Renal Dialysis Facilities, transporting patients to facilities and arranging for new facilities to open in order to serve beneficiaries without interruption. In Texas, CMS is coordinating with the workforce on the ground that cares for renal patients to ensure there are enough facilities to serve beneficiaries in need of dialysis. The agency is accepting requests from end stage renal disease suppliers to become a temporary Special Purpose Renal Dialysis Facility (SPRDF). Since the public health emergencies were declared, CMS has offered immediate administrative relief actions to Texas and Louisiana including issuing several general waivers of certain requirements for specific types of providers in impacted counties and geographical areas. These waivers work to prevent gaps in access to care for beneficiaries. Skilled Nursing Facilities (SNF): CMS waives requirements for a 3-day prior hospitalization before admission in order to receive Medicare SNF services and provides temporary emergency coverage of services in SNFs without a qualifying hospital stay for people who are evacuated, transferred, or otherwise dislocated due to Hurricane Harvey. Certain people with Medicare benefits who recently exhausted their SNF benefits are authorized for renewed coverage without first having to start a new benefit period. Home Health Agencies: This CMS waiver provides relief to Home Health Agencies on the timeframes related to completion of OASIS (assessment data) Transmission. Critical Access Hospitals (CAH): CMS waives the requirements limiting the number of patient beds to 25, and allows for length of stays beyond the capped 96-hour time period. With the public health emergency in effect, CMS can also waive or modify certain Medicare provisions for providers, including certain deadlines, conditions of participation and certification requirements. Providers can now submit waiver requests to the state survey agency or the CMS regional office and they will be evaluated to ensure that they meet the requirements set out under the law. To help clarify billing instructions, CMS has issued technical direction to the Medicare Administrative Contractors regarding the waivers and has reminded area Medicare Advantage plans regarding their responsibilities to relax certain requirements during a disaster or emergency. CMS will continue to work with the States of Texas and Louisiana. The agency continues to update our emergency page (www.cms.gov/emergency) with important information for state and local officials, providers, healthcare facilities and the public. To read previous updates regarding HHS activities related to Hurricane Harvey, please visit https://www.hhs.gov/about/news. To learn more about HHS resources related to Hurricane Harvey, please visit https://www.hhs.gov/hurricane-harvey.  Hurricane Harvey and Medicare Disaster Related Texas Claims MLN Matters Article — New The President declared a state of emergency for Texas and the HHS Secretary declared a Public Health Emergency for Texas which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act.  An MLN Matters Special Edition Article on Hurricane Harvey and Medicare Disaster Related Texas Claims is available.  Learn about blanket waivers CMS issued in the impacted counties and geographical areas in Texas. These waivers will prevent gaps in coverage for beneficiaries impacted by the emergency. Check the Hurricanes webpage for current information on temporary emergency policies and waivers. Additional waiver requests are being reviewed, and the webpage will be updated as decisions are made. Tropical Storm Harvey and Medicare Disaster Related Louisiana Claims MLN Matters Article — New The President declared a state of emergency for Louisiana and the HHS Secretary declared a Public Health Emergency for Louisiana which allows for CMS programmatic waivers based on Section 1135 of the Social Security Act.  An MLN Matters Special Edition Article on Tropical Storm Harvey and Medicare Disaster Related Louisiana Claims is available.  Learn about blanket waivers CMS issued in the impacted counties and geographical areas in Louisiana. These waivers will prevent gaps in coverage for beneficiaries impacted by the emergency. Check the Hurricanes webpage for current information on temporary emergency policies and waivers. Additional waiver requests are being reviewed, and the webpage will be updated as decisions are made. Like the eNews? Have suggestions? Please let us know! The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S. Department of Health and Human Services (HHS).

Medicare shared-savings ACOs cut $1 billion in costs over three years

By Shelby Livingston  | August 29, 2017

(Story updated at 4:33 p.m. ET)

Accountable care organizations participating in the CMS' Medicare shared-savings program reduced spending by about $1 billion in three years, HHS' Office of Inspector General reported Tuesday.

Most of the 428 ACOs in the first three years of the shared-savings program reduced Medicare spending compared to their benchmarks, and a small group of those ACOs produced "substantial" savings.

The majority of the ACOs—82%—also improved the quality of care they provided, based on data from the CMS on 33 individual quality measures. They outperformed fee-for-service providers in 81% of the quality measures.

"While policy changes may be warranted, ACOs show promise in reducing spending and improving quality," the OIG report concluded.

The report shows that the initiative launched under the Affordable Care Act to cut spending, improve care quality and pay doctors based on value rather than volume is working. The findings come just weeks after the Trump administration canceled other alternative payment model experiments, including two mandatory bundled-payment programs, and rolled back another.

The report adds to the growing body of evidence showing that while ACO performance varies widely, ACOs are improving the quality of care overall, said David Muhlestein, chief research officer at Leavitt Partners. Cost savings—the bulk of which are concentrated among just a few ACOs—have trailed improvements in quality, he said, but there's promise for both.

"It's not just about getting paid differently," he said. "It's about providing care differently, and it takes time."

Clif Gaus, president and CEO of the National Association of ACOs, said that beyond the positive cost and quality performance results, the report also shows "a huge acceptance" of the program by physicians and hospitals. The positive findings are also evidence that ACOs should be allowed to remain in one-sided risk contracts instead of being required to enter two-sided risk arrangements, he said.

"This year's report is further proof that one-sided ACOs are doing well," he said. The vast majority of ACOs in the program participate in one-sided risk contracts. But CMS limits one-sided risk ACOs to two contract terms, or six years.

To control the cost of Medicare spending, the CMS implemented several alternative payment models under the ACA. These models, including the shared-savings program, aim to reduce costs while rewarding providers for delivering quality care.

The Medicare shared-savings program is one of the agency's largest attempts to overhaul how hospitals and doctors are paid. Launched in 2012, it accounted for $168 billion in Medicare expenditures over the first three years of the program.

Under the program, groups of doctors, hospitals and other healthcare providers coordinate care for patients and work to reduce unnecessary spending. There were 428 participating shared-savings program ACOs serving 9.7 million beneficiaries in the first three years. Each ACO served an average 18,500 beneficiaries in 2015. ACOs sign three-year contracts with Medicare under the program.

The shared-savings program ties financial incentives to a provider organization's performance on reducing costs compared to a benchmark and hitting quality targets. In the first three years, there were 33 quality targets. Successful ACOs keep a share of the savings they generate for Medicare.

The OIG found that one-third of participating ACOs reduced spending enough to receive a portion of the savings during the first three years of the program. These ACOs reduced spending by about $2.8 billion from 2013 to 2015. Of that amount, the ACOs received $1.3 billion in shared-savings payments, or about $4.8 million each for every year they earned shared savings. They use that money to invest in new care programs, provide incentives to providers to improve quality, or update their electronic health records.

Two-thirds of participating ACOs, or 282 ACOs, reduced spending for at least one of the years they participated in the program. The remaining 146 ACOs did not reduce spending, and they exceeded their benchmarks in spending for each of the years they participated in the program.

In 2015 alone, 57% of ACOs that were in the program for three years reduced spending, while 46% of ACOS in the program for one year reduced spending in 2015. That finding shows that more established ACOs are learning how to achieve greater savings over time, the OIG report stated.

A small group of ACOs, characterized as "high-performing," reduced spending by an average $673 per beneficiary between 2010 and 2015 for key Medicare services, the report found. Other ACOs increased spending by $707 per beneficiary while fee-for-service providers increased spending by an average of $673 per beneficiary.

In total, ACOs reduced spending by $3.4 billion in the first three years of the shared-savings program. About half of that figure was generated by just 36 ACOs. But ACOs that exceeded their benchmarks increased spending by about $2.4 billion during the three-year period, meaning the net reduction in spending across all ACOs was $1 billion.

Participating ACOs also improved the quality of care they delivered to patients. In the program, each ACO receives an overall quality score ranging from 0 to 100. In 2014, ACOs had an average quality score of 86. That figure increased to 91 in 2015.

Moreover, 74% of participating ACOs achieved a quality score of 90 or higher in 2015, up from just 29% in 2014.

ACOs showed the most improvement on two quality measures: They increased the percentage of beneficiaries who were screened for depression from a median of 26% in 2013 to 46% in 2015. ACOs also increased the portion of beneficiaries screened for a fall risk from 35% in 2013 to 59% in 2015, the report stated.

Participating ACOs outperformed fee-for-service providers on most measures. For example, ACOs performed better than 90% of all fee-for-service providers on lowering hospital readmissions.

The number of ACOs participating in the shared-savings program also grew between 2013 and 2015, the OIG report said. While 220 ACOs participated in the program in 2013, that number grew to 333 in the second year and 392 in the third year. The report said a total of 36 ACOs dropped out in the first three years. While ACOs served just 10% of Medicare beneficiaries in 2013, they served 19% of all Medicare members by 2015.

Gaus noted that the majority of ACOs participate in the one-sided risk track of the shared-savings program.

Shelby Livingston is an insurance reporter. Before joining Modern Healthcare in 2016, she covered employee benefits at Business Insurance magazine. She has a master’s degree in journalism from Northwestern University’s Medill School of Journalism and a bachelor’s in English from Clemson University.

http://www.modernhealthcare.com/article/20170829/NEWS/170829881?utm_source=modernhealthcare&utm_medium=email&utm_content=20170829-NEWS-170829881&utm_campaign=am

How to keep ACA stabilization narrow

When Congress returns next week, the health debate will shift from trying to pass sweeping legislation to stabilizing the non-group insurance market. This will be a different debate about a thorny but smaller problem. The weaknesses that need to be fixed are fairly specific, and they don't affect the majority of Americans.

Data: Kaiser Family Foundation; Chart: Andrew Witherspoon / Axios

The bottom line: If Congress can keep the focus on market stabilization and doesn't get mired in another divisive debate about health reform, and the news media can keep this relatively manageable problem in perspective for the public, there is at least a decent chance for bipartisan cooperation and a successful outcome.

The problem: Premiums in the Affordable Care Act marketplaces have been rising sharply, with the average increase for the benchmark "silver plan" up 21% this year. Proposed rates for next year will range from a 49% increase in Wilmington, Delaware to a 5% decrease in Providence, Rhode Island.

But the non-group market is actually fairly small, covering about 18 million people, with about 10 million of them in the ACA marketplaces which have received so much attention.

The perception: A Kaiser Family Foundation poll this month found that when people read headlines or hear about "premiums soaring" in the ACA marketplaces, most Americans — 76% — they think they are hearing about their own premiums, even though the vast majority of Americans are not in the individual insurance market and are not affected. (A smaller but sizeable percentage believe they are affected when they hear about counties with no or limited insurance options in the ACA marketplaces.)

There are several reasons for this, and the media bears some of the responsibility. Health journalists have generally done an outstanding job covering the issue, but sloppy cable headlines, commentary from pundits, and spin from politicians have too often implied that everyone in America is affected when they are not.

For context: In fact, the rest of the health system where most Americans get their coverage looks very different from the non-group market. As the chart shows:

• Average premiums in the employer insurance market, where 151 million Americans get their health coverage, rose by an average of just 3% last year. And we're expecting continued moderation this year.
• Likewise, per capita spending for Medicaid is projected to grow a modest 3% in 2017, with per capita Medicare spending growing by just 2 percent.

The back story: Insurers and regulators have been struggling with a unique set of issues in the non-group market, most especially a sicker than expected risk pool and the uncertainty surrounding Trump administration policies. The most important areas of uncertainty have been whether the administration will continue to pay out the $7 billion in cost sharing subsidies and enforce the individual mandate.

But even before the ACA, the non-group market was also the weak link of the insurance system, with sick people priced out or excluded from coverage altogether.

What to watch: Some think a deal on stabilizing the non-group market could be as narrow as an agreement to appropriate the $7 billion in federal cost sharing subsidies in exchange for greater flexibility for states under the ACA. That might not be a slam dunk if that flexibility trips over third rail issues, such as endangering coverage for people with pre-existing conditions.

But whether the formula for a bipartisan deal is that one or another one, policymakers will have a better chance of addressing the problems in the marketplaces if they forge a narrow agreement. And the debate stands a better chance of not spinning out of control if the news media works overtime to help the public understand who is affected and who is not.

Don’t Become the Catch of the Day

Posted on August 31, 2017 by Jim Borland, Acting Deputy Commissioner for Communications

Verifying and protecting your identity is of great importance to us at Social Security. We dedicated an entire section of our website to explaining how we process your information online and verify Social Security numbers. We include helpful tips you should be aware of on avoiding identity theft schemes and ways to make your online presence more secure! 

Did you know that when Internet fraudsters impersonate a business to trick you into giving out your personal information, it’s called phishing? On our website, you’ll find information on how to detect a phishing scam. For example, emails from Social Security will come from a “.gov” email address. If an email address does not end in “.gov”, use caution before selecting pictures or links in the email. Also, do not respond to emails requesting you provide personal information. Social Security will never ask you to provide personal information via email. You should never respond to an email if you are not certain it came from Social Security. Do not open it or select any links contained in the email message.

Our mission is to provide you with world-class service. Part of that commitment is making sure you know who to trust and what to be cautious about when it comes to personal information and protecting your identity.

https://blog.socialsecurity.gov/dont-become-the-catch-of-the-day/ 

Calif Hits Kaiser With $2.2 Million Fine For Failing To Provide Required Medicaid Data

By Chad Terhune

August 28, 2017

Capitol Desk delivers the latest in health care policy and politics from Sacramento and around the state. Have an idea? Let us know.

California officials have again slapped health care giant Kaiser Permanente with a multimillion-dollar fine for failing to provide data on patient care to the state’s Medicaid program.

The $2.2 million fine comes just months after a $2.5 million penalty in January against Kaiser, one of the largest nonprofit health plans in the country. The California Department of Health Care Services said these are the first fines it has imposed against a Medicaid managed-care plan since at least 2000.

The state agency uses this data on hospital admissions, doctor visits and prescription drugs to help set rates, ensure adequate care is available and monitor how tax dollars are being spent in the $100 billion program, known as Medi-Cal in California.

Kaiser isn’t appealing the latest fine, and the Oakland-based health plan said it expects to deliver the required information by September. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

The reporting lapses are surprising given that Kaiser is known industrywide for pioneering the use of electronic medical records and developing data-driven treatment guidelines. But Kaiser has said its systems and technology were not designed to collect information in the format required by the state. The company said the sanctions were in no way related to the quality of patient care.

“We have recently made significant investments in new technology to help us comply with the new administrative data reporting requirements,” Nathaniel Oubre, Kaiser Permanente’s vice president for Medi-Cal, said in a statement. “We are committed to full compliance.”

Jennifer Kent, Department of Health Care Services director, notified Kaiser of the latest fine in a May 25 letter. She wrote that the insurer was making efforts to resolve the deficiencies, but it still had not complied with state deadlines. One of her deputy directors, Sarah Brooks, said the agency has been trying to get Kaiser to comply with the rules since 2014.

The state “takes very seriously its commitment to ensure contract compliance from Medi-Cal managed-care health plans so members can get the care they need,” Brooks said.

Brooks said additional fines may be imposed depending in part on whether Kaiser’s violations put Medi-Cal out of compliance with federal rules. That could force the state to repay money to the Centers for Medicare & Medicaid Services, which funds the Medi-Cal program jointly with the state.

Kaiser is among 22 health plans that participate in the Medi-Cal program. About 80 percent, or 10.8 million, of Medi-Cal’s 13.5 million enrollees are in managed-care plans. Kaiser serves about 700,000 Medi-Cal enrollees.

In addition to being an insurer, Kaiser runs 39 hospitals across the country and hundreds of clinics. Kaiser operates in eight states and the District of Columbia, but about 70 percent of its 11.8 million members are in California. For 2016, the company had net income of $3.1 billion on revenue of $64.6 billion.

A consumer advocate said it’s disturbing that Kaiser has defied state rules for so long.

“We’ve seen Kaiser use their unique model as an excuse for putting themselves outside the law in the past,” said Carmen Balber, executive director of Consumer Watchdog, a Santa Monica advocacy group. “This demonstrates their hubris.”

In Medi-Cal managed care, the state pays insurers a fixed amount per enrollee to provide comprehensive care. That’s different from the traditional fee-for-service system, in which the state pays medical providers directly for services rendered.

Kaiser has faced other fines from California regulators. In 2013, the California Department of Managed Health Care fined the insurer $4 million for problems with patient access to mental health treatment. In June, the managed-care agency criticized Kaiser again for failing to address long delays in treatment, and it said additional fines were possible.

Chad Terhune: cterhune@kff.org, @chadterhune

http://californiahealthline.org/news/calif-hits-kaiser-with-2-2-million-fine-for-failing-to-provide-required-medicaid-data/

The Medicare Appeals Backlog

The Medicare appeals backlog is significant and has been increasing in recent years. Between 2010 and 2014 the number of Administrative Law Judge (ALJ) appeals grew 936%, from over 41,000 to nearly 433,000 -- by the end of 2014, the number of appeals pending at ALJ rose to close to 800,000. In the wake of this backlog, healthcare providers are typically waiting months if not years for an ALJ hearing; as such, ALJ decisions are almost universally issued well after the 90-day statutory deadline. In 2014, it took OMHA an average of 415 days to process an ALJ appeal; in 2015 that average rose to 662; in 2016 it took OMHA an average of 877 days to process an ALJ appeal.

For providers, these delays are a source of both frustration and financial consequence, primarily due to the fact that Medicare can statutorily recover an alleged overpayment shortly after a second level appeal decision issues, despite the fact that an appeals process may still be in process.
Changes to Address the Backlog

Relief – or at least improvement – appears to be on the horizon. In late 2016, the United States District Court for the District of Columbia ordered that the HHS Secretary reduce the appeals backlog according to the following timeline:

 30% reduction from the current backlog of cases pending at the ALJ level by 12/31/2017
 60% reduction by 12/31/2018
 90% reduction by 12/31/2019
 100% reduction by 12/31/2020.

In an effort to meet these mandated backlog reduction timelines, HHS issued a final rule on 01/17/2017 titled “Medicare Program: Changes to the Medicare Claims and Entitlement, Medicare Advantage Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures.”

This recent final rule, which became effective in March, includes an assortment of initiatives to reduce the backlog, including:

 Giving select Medicare Appeals Council decisions precedential effect -- This is an important improvement due to the fact that, currently, even if the Medicare Appeals Council interprets a Medicare authority or provision in a specific way in a particular decision, that interpretation only applies to the case at hand. Therefore, a provider can’t contend that the interpretation of a Medicare authority or provision in a previous Medicare Appeals Council matter is binding in their case as well, even if the facts and issues are similar. HHS hopes the precedential nature of Medicare Appeals Council decisions will create consistency and efficiency in the appeals process.

 Expanding the pool of adjudicators at OMHA to include attorney adjudicators -- Attorney adjudicators are licensed attorneys employed by OMHA with specific knowledge of Medicare coverage and payment laws. HHS estimates that the expansion of the pool of adjudicators at OMHA could redirect more than 20,000 appeals per year to attorney adjudicators, thereby reducing the ALJ’s workload and speeding appeals processing times.

 Creating process efficiencies -- For example, allowing ALJs to vacate their own dismissals rather than requiring providers to appeal a dismissal to the Medicare Appeals Council.

Countering the Audit Risk

While a CMS authorized audit by a MAC or Supplemental Medicare Reviewer Contractor (SMRC) may be inevitable for many providers, there are steps that can be taken to reduce the risk and/or negative outcomes of an SMRC review, such as:

• Use “trigger” language – while in theory all records should be reviewed in their totality, certain words and phrases are more likely to catch a reviewer’s initial attention if they are not expressly stated.

Examples of such language include:
o “Admit to rehab”
o “D/C destination” on PAS
o “Medical prognosis” on IPOT
o “CLOF/PLOF” on PAPE
o Barriers on Team Conference

• Ensure timestamps -- While an argument can be made that dictation time should determine timeliness, RAC/SMRC/CERT reviewers only consider the document “complete” when it is signed, dated and timed. Therefore, admit orders must be signed before evaluations are initiated and PAPE must be signed within 24 hours.

• Don’t overlook the importance of correctly reported therapy minutes on the IRF PAI-- although CMS has stated the IRF PAI therapy minute data is not to be used as the basis for a denial, it is a ready source for identifying minutes that are under-provided and provided in group or concurrent settings. The data can also be used against a site if the minutes reported don’t add up to what is stated in the documentation.

• Clearly document the need and value to the patient for group therapy minutes -- CMS expects individual minutes to be provided as a preponderance of minutes per week. Some reviewers count the individual versus group/concurrent percentages by discipline, not as a collective total of the minutes provided in a week. If group/concurrent therapy is provided, ensure it is well documented as to need and value to the specific patient’s own clinical needs. Some MACs consider group or concurrent therapy to be “in addition to” the 900 minutes.

Post Payment Denials – Reviews and Appeals

When faced with a claims denial, providers should follow a deliberate and defined process when evaluating why and how to appeal. As a first step, a denial should be carefully reviewed and analyzed. For example, did the reviewer use the correct criteria for denying the stated IRF PAI admission score? Did the reviewer use the correct CMS interpretation of the IRF rules regarding therapy minutes, including group therapy? Did the reviewer use the correct CMS definition of the Rehab Medical Director qualifications? Fully understanding the denial is always the best first step in mounting an appeal.

Once the denial is fully reviewed, there are proven strategies a provider can employ to appeal the denial. Specifically, be sure to address the CMS-stated reasons for the denial and be certain to:

• Reference the IRF PAI instruction manual on how to determine admission IRF FIM scores (lowest in first 3 days, not the highest or average)
• Emphasize medical necessity at key points, including time of admission and throughout the stay
• Distinguish IRF level of care and medical management from lower levels of care in the local community
• Include a copy of the CMS language or definitions, as needed. According to CMS, “one of the primary objectives is to change the focus of IRF medical reviews from what may or may not have happened to the patient’s medical condition during their IRF stay, to what the IRF could’ve reasonably expected to happen given the patient’s condition and risk for clinical complications at the time of admission to the IRF.” For example, suppose that upon admission to an IRF, a patient has a risk for a clinical complication that could interfere with participation in rehabilitation therapy. This is information that would be a reason for the IRF stay to be reasonable and necessary even if the patient’s clinical complication is well managed by the IRF and does not actually cause further difficulties during the patient’s rehabilitation therapy program

Advisory Board split in $2.6B deal with UnitedHealth's Optum buying healthcare business

By Alex Kacik  | August 29, 2017

(Story updated at 2 p.m. ET) 

The Advisory Board Co. will be acquired by UnitedHealth Group and a private equity firm in an estimated $2.58 billion deal that splits the consulting group's healthcare business from its education arm, the companies announced Tuesday.

UnitedHealth's Optum health-services segment will take over the Advisory Board's healthcare business for an estimated $1.3 billion. The Advisory Board provides independent research, advisory services and data analytics for more than 4,400 healthcare organizations.

Advisory Board shareholders will net estimated cash per share of $54.29, which includes a fixed payment of $52.65 per share and the after-tax value of its 7.6% stake in Evolent Health.

"By working together, The Advisory Board Company and Optum will provide deeper strategic insights and practical operational value to clients who are looking for ways to enhance care and respond to the changing market dynamics of the health care system," Optum CEO Larry Renfro said in a statement.

Private equity firm Vista Equity Partners Management will acquire the Advisory Board's education business known as EAB, which includes the Royall & Co. division, for $1.55 billion. EAB, which provides research and technology services for more than 1,200 educational institutions, will operate as a stand-alone business.

After that deal closes, expected by the end of 2017 or in early 2018 after Advisory Board shareholder and regulatory approval, UnitedHealth will pay $1.3 billion including the assumption of debt for the Advisory Board's health operation.

"We determined that transactions with Optum and Vista Equity Partners allow us to accelerate the success of our healthcare and education businesses while realizing immediate value for stockholders," Robert Musslewhite, chairman and CEO of the Advisory Board, said in a statement. "We believe this is the best course of action for our stockholders, members and employees."

The Advisory Board said in February that it has been shopping the investor-owned company around when Elliott Management Corp. and related entities bought about 8.3% of its shares. The company said in January that it would lay off 220 employees as part of a restructuring process to save approximately $25 million in operating expenses by the end of the year.

Earlier this year, the company blamed some of its difficulties on uncertainty in the industry following the election, "as members reassessed their strategy and path forward."

Alex Kacik is the hospital operations reporter for Modern Healthcare in Chicago. Aside from hospital operations, he covers supply chain, legal and finance. Before joining Modern Healthcare in 2017, Kacik covered various business beats for seven years in the Santa Barbara, California region. He received a bachelor's degree in journalism from Cal Poly San Luis Obispo in Central California.

http://www.modernhealthcare.com/article/20170829/NEWS/170829882?utm_source=modernhealthcare&utm_medium=email&utm_content=20170829-NEWS-170829882&utm_campaign=am

Providers feel the pain of slow Medicaid mental services rule rollout

By Virgil Dickson  | August 29, 2017

David Ramsey's hospitals and emergency departments in West Virginia see the effects of the opioid epidemic every day. Medicaid beneficiaries battling addiction and psychiatric disorders crowd into his emergency departments even though the CMS has launched a nationwide policy to pay for substance abuse treatment and stays at inpatient psychiatric facilities.

But a year after that Medicaid policy became effective nationwide, Ramsey's hospitals have seen no relief. Each week, Ramsey's Charleston Area Medical Center has to ask a local court to conduct mental hygiene hearings that Medicaid patients need in order for the state to approve their transfer to a free-standing psychiatric hospital that can provide them better care for their severe mental health or substance abuse issues.

In the meantime, those patients are spending hours or days in his emergency departments, unable to get the level of care they need. Unlike general acute-care hospitals, free-standing psychiatric facilities have staff that specialize in a gamut of mental illnesses.

"It's pretty silly really. The need is sort of off the charts, especially with the opioid epidemic," said Ramsey, CEO of the Charleston Area Medical Center. "We see the need in our ER every day and to not have access to an available resource is pretty sad."

Hospitals across the country are experiencing similar pains as states slowly work to lift the decades-old ban against reimbursement for institutions of mental disease, or IMDs. Since Medicaid's creation 50 years ago, the program has refused to pay for treatment at IMDs, which include most residential treatment facilities for mental health and substance use disorders with more than 16 beds.

Last year, the CMS finalized a policy allowing Medicaid managed-care plans to pay IMDs for short-term stays lasting 15 or fewer days in a month. The CMS estimates that 7.1% of adults ages 21 to 64 meet the criteria for serious mental illness that requires at least some inpatient treatment and that 13.8% experience serious substance abuse disorders. The rate of need, as well as years of state requests, led the agency to grant the new permission.

As of August, only seven of the 39 states with managed-care Medicaid programs have started paying IMDs for those stays, according to email responses to a Modern Healthcare inquiry from state Medicaid agencies. Those states are Florida, Indiana, Michigan, Ohio, Rhode Island, Tennessee and Wisconsin.

States that haven't started paying for Medicaid beneficiaries' IMD stays say they are still trying to figure out how to develop rates for the facilities or have pending waivers with the CMS to pay for more than 15 days of care.

West Virginia officials also said they were concerned about a provision in the managed-care rule that asked them to take back any reimbursement paid out by a managed-care plan for treatment that surpassed the 15-day limit.

"There are serious operational challenges to implement this recoupment provision, which requires the ability to track individual IMD stays and set up processes for recouping back-rate payments from plans retrospectively," said Allison Adler, a spokeswoman with West Virgina's Department of Health. The state now has a waiver pending with the CMS to pay for up to 30 days of treatment.

Other managed-care states such as California and Maryland say their plans are not paying for the services because behavioral health is carved out of managed-care contracts, and they are only offered on a fee-for-service basis. The CMS rule only lifted the IMD ban for managed-care cases. It would take legislation to lift the ban for Medicaid beneficiaries not in managed care.

The IMD exclusion has meant Medicaid beneficiaries suffering from mental illness experience tumultuous care, according to Mark Covall, president of the National Association of Psychiatric Health Systems. Patients endure long stays in emergency departments and are transferred around from one general acute-care hospital to another, sometimes far from their homes, because of bed shortages.

If no beds are available at an acute-care hospital, patients are referred to a state-run, stand-alone psychiatric facility. Under the Emergency Medical Treatment and Labor Act, those facilities can't deny patients admission, even though they won't be paid for their services because of the IMD exclusion. Instead, they often discharge patients early, and those patients receive lower quality care, providers say.

Dr. Patrick Runnels, program director of public and community psychiatry at University Hospitals of Cleveland, said even though Ohio now pays for care at psychiatric facilities, he has seen little benefit to his health system. The Cleveland area already had a psychiatric bed shortage, and for-profit facilities in the area that may have bed openings aren't interested in Medicaid patients.

"Their business models are predicated on admitting people who who have payers that pay more for psychiatric treatment and Medicaid pays the least, so it's a lost race," Runnels said.

Some private psychiatric facilities welcome Medicaid patients, according to Jim Shaheen, founder and president of Strategic Behavioral Health, which owns and operates a chain of 10 facilities around the country.

He has expanded the number of beds at some of his locations and is now constructing two new facilities in Iowa and Tennessee, partially in response to the new Medicaid policy.

"This has impacted our ability to build more hospitals because this population is now available to us," Shaheen said. "There was a whole subset of the behavioral health population that was not able to access care."

Shaheen acknowledges that Medicaid is a low payer, covering as little as 45% to 50% of cost, but he still wants to be a resource for this population. Even if states take a while to pay for IMD services for adults, he feels confident that he'll get enough patients from other payers until additional Medicaid enrollees are able to get care at his facilities.

Others say the lethargic rollout has nothing to do with the states, and everything to do with managed-care plans not wanting to spend the money on substance abuse and inpatient psychiatric treatment. An average inpatient weekly stay at an inpatient behavioral health facility can range from $4,000 to $6,000 or even more, according to national health data.

The National Association of State Mental Health Program Directors said that managed-care organizations have complained to the CMS that they feel it's too difficult to implement the new policy, according to Stuart Gordon, the association's director of policy and healthcare reform. "They are choosing not to offer the services under their contracts with the states," Gordon said. "The rule does not require them to do so, only authorizes the states to contract for the services."

A CMS spokesman did not return a request for comment. Alexander Shekhdar, vice president of federal and state policy at Medicaid Health Plans of America, said that managed-care plans are not blocking the IMD policy rollout and implementation decisions rest with the states.

In West Virginia, a resident dies roughly every 10 hours due to opioid addiction. The Charleston Area Medical Center's Ramsey says he's hopeful the state will soon start paying Medicaid beneficiaries' treatment.

"This should all be moving forward as fast as possible," he said.

Virgil Dickson reports from Washington on the federal regulatory agencies. His experience before joining Modern Healthcare in 2013 includes serving as the Washington-based correspondent for PRWeek and as an editor/reporter for FDA News. Dickson earned a bachelor's degree from DePaul University in 2007.

http://www.modernhealthcare.com/article/20170829/NEWS/170829876?utm_source=modernhealthcare&utm_medium=email&utm_content=20170829-NEWS-170829876&utm_campaign=am

CMS posts 2015 Inpatient and Outpatient Hospital Utilization and Payment Data

CMS has released the Hospital Inpatient and Outpatient Utilization and Payment Public Use Files (PUF) with data for 2015.

The Inpatient PUF includes summarized information on inpatient discharges paid for under the Medicare Inpatient Prospective Payment System (IPPS) for Medicare fee-for-service beneficiaries. The data include discharges, average Medicare payments and average hospital charges organized by hospital provider and Medicare Severity Diagnosis Related Group (MS-DRG). It provides data on more than 3,000 hospital providers who collectively received $78.2 billion in Medicare payments in 2015. The 2015 data and supplemental information are available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Inpatient2015.html.

The Outpatient PUF includes summarized information on select outpatient services and procedures paid for under the Medicare Outpatient Prospective Payment System (OPPS) for Medicare fee-for-service beneficiaries. The data include services, average total payments and average hospital charges organized by hospital provider and Ambulatory Payment Classification (APC) Groups. It provides data on more than 3,000 hospital providers who collectively received $5.4 billion in total payments in 2015.  The Outpatient PUF and the supplemental summary tables for 2015 have been updated to include 28 APC Groups and are available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/Outpatient2015.html.

June 2017 monthly report on state Medicaid and Children's Health Insurance Program (CHIP)

Today the Centers for Medicare & Medicaid Services (CMS) released the June 2017 monthly report on state Medicaid and Children's Health Insurance Program (CHIP) eligibility and enrollment data. The full report is available on Medicaid.gov at  https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

New videos highlight ways to support long-term care in tribal communities Kiowa-Choctaw artist and filmmaker Steven Paul Judd describes ways tribes can provide long-term care to elders and people with disabilities in five new videos from the Centers for Medicare & Medicaid Services (CMS). The videos use animation to illustrate culturally appropriate and tribally driven ways to improve the lives of elders, people with disabilities, and their families. The series covers: Traditional Foods for Tribal Elders (0:31) Dementia and Alzheimer’s Care for Tribal Elders (0:46) Home-Based Care for Elders and Tribal Members with Disabilities (0:34) Tribal Support for Caregivers (0:41) Financing Tribal Long-term Services and Supports (0:47)