Friday, June 29, 2018

Judge blocks Kentucky's Medicaid work requirement

By Harris Meyer  | June 29, 2018
Updated at 7:10 p.m. ET

A federal judge's ruling Friday invalidated the CMS' approval of a Medicaid waiver that would have let Kentucky impose work requirements and other tough new conditions for eligibility on beneficiaries. The decision, while dealing a blow to the Trump administration's strategy for revamping and shrinking Medicaid, left the door open for legal clearance for a more carefully developed model.

U.S. District Judge James Boasberg in Washington, D.C., an Obama administration appointee, held in Stewart v. Azar that the HHS secretary's approval of the waiver failed to take into account the primary objective of the Medicaid statute, which he said is to furnish medical assistance. The judge sent the waiver back to the CMS for further review.

"The secretary must adequately consider the effect of any demonstration project on the state's ability to help provide medical coverage," Boasberg wrote in his 80-page decision. "He never did so here."

The U.S. Department of Justice is likely to request a stay of Boasberg's ruling to allow the five-year demonstration to take effect July 1 as scheduled, and to appeal the decision to the U.S. Court of Appeals for the District of Columbia Circuit.

At a time when the Trump administration is rolling back the Affordable Care Act through a variety of administrative actions, Friday's ruling was a rare bright moment for ACA supporters. The federal government has never previously permitted states to impose work requirements as a condition of Medicaid eligibility.

Legal observers believe the case eventually could reach the U.S. Supreme Court, which, by that time, will have at least one new member named by President Donald Trump. The president said Friday that he intends to name is nominee to replace retiring justice Anthony Kennedy by July 9. Senate Majority Leader Mitch McConnell (R-Ky.) has indicated that he wants to move quickly to fill the seat.

"A staunch conservative may be more receptive to the kinds of changes the Trump administration is making to Medicaid than a progressive justice," said Nicholas Bagley, a University of Michigan law professor.

CMS Administrator Seema Verma called the ruling "disappointing" but said her agency "is conferring with the Department of Justice to chart a path forward. In the meantime, we will continue to support innovative, state-driven policies that are designed to advance the objectives of the Medicaid program by improving health outcomes for thousands of low-income Americans."

Kentucky's Republican governor, Matt Bevin, pushed hard for the waiver and warned that if it were challenged in court, he would end the state's expansion of Medicaid under the Affordable Care Act. That expansion, launched by his Democratic predecessor, has expanded coverage to nearly 500,000 low-income adults and helped cut the state's uninsured rate by nearly half.

"While we disagree with the Court's ruling, we look forward to working with CMS to quickly resolve the single issue raised by the court so that we can move forward with Kentucky HEALTH," said Adam Meier, the state's secretary of Health and Family Services. "Without prompt implementation of Kentucky HEALTH, we will have no choice but to make significant benefit reductions."

The Kentucky Hospital Association, which supported the waiver in order to protect the Medicaid expansion, disagreed with Boasberg's finding that HHS' approval of the waiver was arbitrary and capricious. "The association found the waiver process to be engaging, thorough, and evidence-based," said Wes Butler, outside counsel for the hospital association. "Kentucky hospitals remain committed to working with state and federal Medicaid agencies to consider program innovations."

Unlike in Kentucky, many hospital and provider groups oppose a Medicaid work requirement, fearing coverage losses, a jump in uncompensated care, and disruption of care for people with chronic conditions.

Jane Perkins, lead attorney for the three advocacy groups that brought the lawsuit on behalf of 16 Kentucky Medicaid beneficiaries, said the court put the Trump administration on notice that if it wants to implement a Section 1115 Medicaid experiment, it must follow the purpose of Medicaid, which is to provide coverage, not cut it. Kentucky projected that 95,000 people would leave Medicaid over five years due to the waiver, though outside groups estimated the number would be far larger.

Now, Perkins and her colleagues are considering filing lawsuits challenging similar Medicaid work requirement waivers in Arkansas, Indiana, and New Hampshire. Those state waivers were not part of the Kentucky case and will move forward unless explicty challenged and overturned in court. Those demonstrations were approved after the CMS in January invited states to submit such proposals. Arkansas' work requirement took effect June 1. Arizona, Maine, Mississippi, Michigan, Utah and Wisconsin have waivers awaiting approval from the CMS.

The Kentucky waiver program requires that starting in July, non-disabled beneficiaries have to complete 80 hours per month of employment or other community engagement activities to maintain their Medicaid eligibility. That applies to both the traditional Medicaid population and the expansion population. All beneficiaries will have to regularly document their compliance or prove that they qualify for an exemption.

The CMS and the Bevin administration argue that requiring people to work or participate in other community engagement activities will improve their health and help shift them into commercial health insurance.

The waiver also establishes premium payments, cost-sharing, a lockout for failure to pay, an end to retrospective eligibility, and elimination of non-emergency medical transportation. The plaintiffs in the lawsuit are challenging the legality of all those provisions.

Under Kentucky's demonstration, premiums will range from $1 a month for people with little or no income and up to $37.50 a month for people at 138% of the federal poverty level. Those above the poverty line who fail to pay will be locked out of coverage for six months and must pay past-due premiums to regain coverage. Those below the poverty line who don't pay will have their reward accounts for receiving vision and dental benefits docked.

Boasberg's ruling knocked out all provisions of the Kentucky HEALTH model except an enhanced new program for substance abuse treatment under Medicaid.

There currently are more than 1 million Kentuckians on Medicaid.

A Kaiser Family Foundation report estimated that as many as four million Americans would lose coverage if similar work and community-engagement rules were adopted nationwide.

The Justice Department argued that the HHS secretary's discretion in granting Medicaid Section 1115 waivers is not reviewable by the courts if the secretary makes the judgment that a demonstration project supports the Medicaid statute's objectives.

But Boasberg wrote that while the secretary is given significant deference in approving pilot projects, "his discretion does not insulate him entirely from judicial review. Such review reveals that the secretary never adequately considered whether Kentucky HEALTH would in fact help the state furnish medical assistance to its citizens, a central objective of Medicaid. This signal omission renders his determination arbitrary and capricious."

The ruling, however, leaves room for the work requirement waiver in Kentucky to ultimately move forward. If the decision is upheld on appeal, the CMS likely would have to work with Kentucky to recraft its waiver proposal, the state would have to open a new public comment period, and the CMS would have to go through a fresh approval process.

"There's no sweeping pronouncement that you can never have a work requirement," said Sara Rosenbaum, a professor of health law and policy at George Washington University, who opposes the Kentucky waiver. "But the court is very clear that when the Secretary exercises Section 1115 authority, the secretary must show with evidence how the demonstration will advance the core purpose of Medicaid, which is to insure people."

But James Blumstein, a Vanderbilt University law professor, find Boasberg's opinion unpersuasive. "I thought the point of an experiment is to find out what happens," he said. "But the court worries that the agency has not considered the outcomes, which is something that occurs once the experiment develops the evidence."

Despite the caveats, Friday's ruling was cheered by ACA supporters, who see Medicaid work requirements as political camouflage for the Trump administration and GOP state leaders to slash the number of people receiving Medicaid and roll back the ACA's coverage expansion.

"Striking down Medicaid work requirements on the legal merits is a big roadblock in the way of instituting such requirements, not only in Kentucky but in any red states that are thinking of moving forward," the University of Michigan's Bagley said.

Harris Meyer is a senior reporter providing news and analysis on a broad range of healthcare topics. He served as managing editor of Modern Healthcare from 2013 to 2015. His more than three decades of journalism experience includes freelance reporting for Health Affairs, Kaiser Health News and other publications; law editor at the Daily Business Review in Miami; staff writer at the New Times alternative weekly in Fort Lauderdale, Fla.; senior writer at Hospitals & Health Networks; national correspondent at American Medical News; and health unit researcher at WMAQ-TV News in Chicago. A graduate of Northwestern University, Meyer won the 2000 Gerald Loeb Award for Distinguished Business and Financial Journalism.
http://www.modernhealthcare.com/article/20180629/NEWS/180629902?utm_source=modernhealthcare&utm_medium=email&utm_content=20180629-NEWS-180629902&utm_campaign=dose

Feds boast largest healthcare fraud takedown ever at $2B in false claims

June 29, 2018
Dive Brief:
  • The Department of Justice announced its largest healthcare fraud takedown ever, charging 601 people for falsely billing Medicare, Medicaid and the U.S. military’s TRICARE program to the tune of more than $2 billion.
  • The massive enforcement initiative — which spanned 58 federal districts — swept up 165 doctors, nurses and other licensed health professionals, including 76 doctors accused of prescribing and distributing opioids and other prescription painkillers.
  • Since last July, HHS has barred 2,700 people from participating in federal healthcare programs, including 587 providers charged with opioid diversion and abuse.
Dive Insight:
Ashlee McFarlane, former federal prosecutor and partner at Gerger Khalil & Hennessy, told Healthcare Dive via email that the takedown shows DOJ “is committing significant resources to criminally prosecuting anyone who prescribes drugs or distributes opioid prescriptions outside the normal course of medical practice. … Federal authorities are sending a message about opioid drug abuse in our nation and using the hammer of criminal prosecution to combat it.”
Indeed, 162 of the 165 medical professionals nabbed in the sting were charged with opioid-related crimes. The takedown serves as a cautionary tale for providers that avoiding any suggestion of over-prescribing and diversion isn't just good for patients’ health — it can save them costly fines, loss of government reimbursement and even jail time.
The investigations included 84 opioid cases involving more than 13 million illegal doses of opioids, according to DOJ.
Among those caught in the crackdown were 124 defendants in DOJ’s South Florida district for false claims totaling more than $337 million. One sober living facility illegally recruited patients, paid kickbacks and conducted fraudulent urine testing, billing the government more than $106 million for alleged substance abuse treatments.
In a Michigan case, a doctor paid kickbacks to two home health agency owners, resulting in more than $12 million in false insurance claims.  The widespread operations were led by DOJ’s Health Care Fraud Unit in conjunction with the Medicare Fraud Strike Force, a collaboration of DOJ’s criminal division, U.S. attorney’s offices, the Federal Bureau of Investigation and HHS’ Office of Inspector General.
“These are despicable crimes,” Attorney General Jeff Sessions said in a statement. “That’s why this Department of Justice has taken historic new steps to go after fraudsters, including hiring more prosecutors and leveraging the power of data analytics.”
In fiscal year 2017, the federal government won or negotiated more than $2.4 billion in healthcare fraud judgments and settlements.
In all, the government reclaimed $2.6 billion last year, including $1.4 billion for the Medicare Trust Funds and $406.7 million in federal Medicaid money. DOJ opened 967 criminal healthcare fraud investigations and filed 439 cases involving 720 defendants. Of those, 639 were convicted.
https://www.healthcaredive.com/news/feds-boast-largest-healthcare-fraud-takedown-ever-at-2b-in-false-claims/526824/

Hospitals roll out online price estimators as CMS presses for transparency


By Harris Meyer  | June 23, 2018
Leaders at El Camino Hospital, located in California's Silicon Valley, wanted to make it easy for tech-savvy consumers to shop online for personalized, reliable price estimates for its medical services.

The independent not-for-profit hospital launched a consumer self-service tool in May 2017, after about a year of development work with Experian Health, which previously helped El Camino set up an internal price-estimator tool for its billing staff.

Since then, more than 3,000 people have visited the hospital's website, selected one or more of about 90 medical or surgical services they were interested in, entered their insurance information, and received an instant out-of-pocket cost estimate the hospital claims is 95% to 99% accurate.

Over the past two years, a growing number of hospitals have worked with vendors such as Experian and Recondo to offer online price estimates directly to consumers for common, less complex services. Previous tools allowed hospital staff to generate estimates for patients when they called or came in for a service.

Now, more providers want to offer self-service cost estimators on their websites. That's because they're experiencing strong demand from patients in high-deductible health plans who want to shop around and know their financial exposure in advance. When patients understand how much they'll owe, that can improve the collection process and reduce uncompensated care, hospital leaders say.

http://www.modernhealthcare.com/apps/pbcsi.dll/storyimage/CH/20180623/NEWS/180629994/H2/0/H2-180629994.jpg?lmt=201806290023&q=70&maxw=600&maxh=600
"A lot of people don't have time to make phone calls or wait for a callback, they want an answer right away," said Terri Manifesto, El Camino's senior director of revenue cycle. "They expect this kind of information online. It's a great thing to offer patients."

The hospital spends about $18,000 a year to provide the service, which currently offers estimates for 35 lab tests, 25 imaging or radiological procedures and about 30 surgical or other medical services.

Providers face mounting pressure from regulators and consumers to be transparent about costs, especially given increasing public anger about unexpected large bills. The CMS recently proposed a rule requiring hospitals to publish online a list of their standard charges in a machine-readable format and update the information at least once a year.

Still, experts note there are limits to the types of services for which consumers are able to price-shop. There is a risk they can get confused about more complex services and blame providers for underestimating the final cost. Vendors are still working on improving the reliability of the estimates, particularly for surgical procedures involving more cost variables.

Up to now, many hospital leaders have contended that insurers are better equipped to tell patients what they'll owe for particular services, claiming there's no infrastructure in place giving providers access to the necessary information. But that argument may be losing credibility as more hospitals partner with vendors to offer patients out-of-pocket cost estimates.

"There are enough examples now that show if providers want to offer better information to consumers, they can build the capacity to do it," said Suzanne Delbanco, executive director of Catalyst for Payment Reform, which monitors healthcare transparency efforts. "It clearly can be done, and symbolically it's the right thing for providers to do."

Online patient price-estimator tools for hospitals and healthcare providers represent a growing market for vendors. "This is an absolute area of interest based on regulation, high-deductible plans and increased patient responsibility for bills," said John Yount, vice president of healthcare solutions at TransUnion, which hopes to have a patient self-service tool on the market by the end of this year.

Franklin, Tenn.-based Experian, which offered its first price-estimator tool for hospitals' internal use in 2008, now has about 10 customers—including hospitals, physician groups, and outpatient and imaging centers—that have gone live with the company's online tool for consumers. It tested the product at St. Clair Hospital in Pittsburgh, which in 2016 became the first hospital to offer it to patients.

Experian's product calculates patients' out-of-pocket cost based on the hospital's chargemaster price, its claims history for providing that service, its contract terms with the patient's insurer, and the patient's benefit structure and deductible status. It also estimates out-of-pocket costs for self-pay patients. The estimate currently covers just the facility fee, though El Camino wants to add professional fees into calculations available through the tool.

In addition to having the option of including facility fees alone in the estimate or including professional fees, providers have the option to present only the patient's out-of-pocket cost, or they can also disclose their actual charges and insurance payment rates. Vendors say providers in more competitive markets typically choose to display only the patient's out-of-pocket responsibility to avoid letting rivals see proprietary rate information.

"Offering an online price estimator is a marketing advantage for hospitals and medical groups that want to be transparent with patients," said Merideth Wilson, a senior vice president at Experian, which charges clients a one-time implementation fee and a monthly maintenance fee based on patient visit volume. "Our customers say it helps with consumer satisfaction, bringing patients back, and bringing more patients in."

Denver-based Recondo released its online cost estimator, called MySurePayHealth, three years ago, and now has about a dozen hospital systems, including Baylor Scott & White Health and ProMedica, using it. The accuracy of its estimates ranges from 75% to nearly 90%, depending on the complexity of the medical or surgical service, said Heather Kawamoto, vice president of products for Recondo, which charges clients a monthly subscription fee based on patient visit volume.

Some Recondo hospital clients, particularly those that own sizable physician practices, include professional fees in the estimate, which makes it much more useful to patients, she said. The tool also asks users if they want a hospital financial counselor to call to discuss a possible loan or charity-care arrangement.

"If the patient has concerns about ability to pay, our clients want to proactively engage in that conversation and put the patient in the best position to pay for that care," Kawamoto said.

Quality indicators absent
These price-estimator tools currently do not offer any type of quality of care, outcomes, or patient satisfaction information to allow consumers to factor those into their shopping decision, though El Camino officials say they hope to build that in.

Delbanco said the lack of quality data is one problem with these tools. Another is that the estimate consumers receive may not reflect the full cost of the care because the professional fees are missing and an episode of care may include unanticipated additional services. A hospital's online price estimator "is not the optimal choice for consumers but it's certainly better than nothing," she said.

El Camino's Manifesto is trying to figure out whether offering the online cost estimator has boosted her hospital's revenue. "We're pretty excited that more than 3,000 consumers ran price estimates in one year's time," she said. "Now it would be great to know if they actually came in for services."

Harris Meyer is a senior reporter providing news and analysis on a broad range of healthcare topics. He served as managing editor of Modern Healthcare from 2013 to 2015. His more than three decades of journalism experience includes freelance reporting for Health Affairs, Kaiser Health News and other publications; law editor at the Daily Business Review in Miami; staff writer at the New Times alternative weekly in Fort Lauderdale, Fla.; senior writer at Hospitals & Health Networks; national correspondent at American Medical News; and health unit researcher at WMAQ-TV News in Chicago. A graduate of Northwestern University, Meyer won the 2000 Gerald Loeb Award for Distinguished Business and Financial Journalism.

CMS Regulator Changes Create More Marketing Flexibility for MA Plans


Jun 27, 2018
Recent regulatory changes as well as program modifications being considered by CMS will likely allow greater flexibility in Medicare Advantage plans’ efforts to engage MA and Part D plan members throughout the year. One of these is the reinstatement of the MA open enrollment period (OEP), which allows members to switch plans during the first 90 days of the year.
While the return of the OEP technically gives plans more time to attract potential enrollees, it also adds to marketing budgets and means customer retention is more important than ever, said Matt Feret, chief sales officer and executive director, Medicare, with Aetna Inc., who spoke at the Second National Medicare Advantage Summit.
Plans will have to be careful not to engage in “targeted marketing” efforts that would, for example, go after competitors’ enrollees and inform them of the opportunity to switch, said health care attorney Kelli Back at the conference. More general, educational material will be acceptable, added Back and Feret.
Another meaningful marketing-related change in CMS’s recent rule is the addition of “communications” to the newly renamed Medicare Communications and Marketing Guidelines that are revised annually. By categorizing certain items as communications, this created a much narrower definition of marketing materials that are subject to agency review, said Back.
Also speaking at the conference, Michael Adelberg, a principal with FaegreBD Consulting and a former top CMS MA official, pointed out that CMS in the past five years has imposed 16 fines for activities that fall under a broad definition of marketing and communications. With more and more plans coming onto the market and CMS providing greater marketing flexibilities, it will be important that plans continue to make sure their practices are in sync with current guidelines.

GAO: 340B hospitals, contract pharmacies need more oversight

June 29, 2018
Dive Brief:
  • The Government Accountability Office said Wednesday that HHS’ Health Resources and Services Administration (HRSA) should take new steps to ensure outside pharmacies that 340B participants use to dispense medicines are compliant with the 340B Drug Pricing Program.
  • The report, requested by the House Energy & Commerce Committee, found that one-third of covered 340B participants contract with outside pharmacies. GAO found that HRSA’s audits do not properly examine compliance with a program requirement that there cannot be duplicate discounts for drugs prescribed to Medicaid recipients.
  • The GAO report is the latest in a slate of scrutiny for the 340B program, which critics say has outgrown its initial purpose. On June 19, the Senate HELP Committee questioned HRSA Director Krista Pedley, who said legislation is needed to grant authority to HRSA to increase oversight of the program.
Dive Insight:
GAO noted that manufacturers cannot be required to give both a 340B discount and an additional rebate through the Medicaid Drug Rebate Program.
“HRSA only assesses the potential for duplicate discounts in Medicaid fee-for-service and not Medicaid managed care. As a result, it cannot ensure compliance with this requirement for the majority of Medicaid prescriptions, which occur under managed care,” GAO wrote.
The watchdog recommended that HRSA examine for duplicative discounts in Medicaid managed care, require more information on how 340B covered entities determine noncompliance issues and require evidence of corrective actions before closing audits.
HHS responded to GAO that while it agrees with some of the recommendations, more resources and regulatory authority are needed to implement others. The additional audit requirements would also impose “significant burden — on covered entities, especially smaller entities who are often resource constrained.”
“Successful implementation would require significant expansion of the Program’s current information technology systems to account for new audit functions as well as strengthened enforcement authority and additional staff to oversee these efforts,” HHS wrote. In addition, disclosing information about fees contract pharmacies collect from covered entities could result in “disruptions in the drug pricing market,” the department said.
340B Health, which represents several hospitals and health systems participating in the 340B program, agreed with HHS that some of the GAO recommendations would be burdensome.
“We are concerned that some of these recommendations could make program participation significantly more cumbersome for hospitals without improving transparency or compliance,” 340B Health said in a statement.
But E&C GOP leaders say the GAO report is the latest example that changes are needed to ensure oversight of the program.
“It is clear that we must continue to examine how this program is working with the goal of ensuring the program properly enables safety net providers to truly help patients in need,” E&C Chairman Greg Walden, R-Ore., and E&C Health Subcommittee Chairman Michael Burgess, R-Texas, said in a statement.
https://www.healthcaredive.com/news/gao-340b-hospitals-contract-pharmacies-need-more-oversight/526867/

Bind Benefits trying on-demand coverage for health insurance


June 29, 2018
Dive Brief:
  • A Minneapolis-based startup founded by former Dignity Health CEO Tony Miller is offering companies and employees a way to purchase health insurance on-demand, CNBC reported.
  • Using machine learning and algorithms, Bind Benefits breaks out specific procedures to lower costs. Its plans have no deductibles for primary care, specialist visits, maternity and hospital care, medications and cancer treatment. Basic co-pays for core medical coverage are priced on a sliding scale. Extra co-pays for elective procedures are based on the total cost, which consumers get ahead of time. 
  • The 2-year-old startup’s financial backers include Ascension Ventures, Lemhi Ventures and UnitedHealthcare. 
Dive Insight:
On-demand services are growing, with companies like Uber and Lyft for transportation and Blue Apron meal kits. Bind’s à la carte approach to coverage could encourage more people to get insured and eliminate fears of surprise medical bills for uncovered services.
The company’s mobile app allows users to compare costs for services and procedures at different sites, such as retail clinics and urgent care centers.
Bind officially launched in February following a $60 million funding roundled by Lemhi Ventures, where Miller is a managing partner.
By being up-front about costs, Bind can help employees and employers save up to 15%, Miller told CNBC.
“A market might be $6,000 to $24,000 for knee arthroscopy,” he said. “What Bind does is say (for) the $6,000 performer — you only have to pay $1,000 to have access to them. If you want to go to the $24,000 knee arthroscopy with no difference in quality, no difference in performance, you have to pay $6,000 as a consumer.”
Other startups have tried to disrupt the traditional health insurance market. For example, Oscar Health launched in 2012 with the idea of using technology and data to improve the customer experience. The company, which began with a focus on Affordable Care Act plans, includes a mobile app for scheduling appointments and doctor consults.
Oscar recently raised $165 million from a group of investors, boosting the company’s value to more than $3 million. The company announced plans to expand its marketplace footprint.

Cerner's VA go-live expected in 2020


June 28, 2018
Dive Brief:
  • The U.S. Department of Veterans Affairs will begin implementing Cerner’s EHR in October in three Pacific Northwest hospitals and go live in March 2020, Acting VA Secretary Peter O’Rourke told a House committee Tuesday.
  • The hospitals in Seattle, Spokane and American Lake, Washington, will be the first to undergo modernization under a 10-year project to overhaul the VA’s medical records system.
  • Lawmakers at the Committee on Veterans Affairs hearing expressed concerns that a lack of stable leadership and transparency at the mammoth department could undermine the effort. “Leadership will make or break this project,” Rep. Tim Walz, D-Minnesota, said. 
Dive Insight:
O’Rourke said the VA is working closely with the Department of Defense to avoid some of the problems DoD has encountered in its own implementation of Cerner’s EHR, and to “collaborate on best practices for business, functional, and IT workflows, with an emphasis on ensuring interoperability between the two agencies.” The Coast Guard is also joiningDoD's rollout.
On Wednesday, VA Secretary nominee Robert Wilkie said during a hearing on his candidacy said he would not commit to going live with a new EHR system until it had been properly tested.
The VA’s Program Management Office will oversee costs, schedule and performance-quality objectives of the project and ensure risk-mitigation strategies are deployed where appropriate.
The project is set to replace the VA’s homegrown VistA medical records system, which is 40 years old and showing clear sign of wear and tear.
Cerner signed the contract in May. The company first announced the $10 billion no-bid contract in June 2017, but it was slow getting off the ground due to interoperability issues and reports that President Donald Trump’s inner circle may have influenced the delay.
Cerner blamed the slow progress for weaker-than-expected revenue growth in the first quarter of this year, despite a 12% year-over-year increase in bookings.
Walz pressed for additional oversight of the contract outside the VA. “The Government Accountability Office should be in attendance at every single governing board,” he said. “GAO must have direct and frequent access to VA, Cerner and program management support contractors.”
Committee Chairman Phil Roe, R-Tennessee, emphasized the size of the project. “$15.8 billion over 10 years, including $10 billion to Cerner, is a staggering number for an enormous government agency,” he said. “The EHR modernization effort is not just a technology project. It will have a major impact on how the Veterans Health Administration operates,” such as clinical and administrative workflows and culture.
The House is forming a small oversight panel to monitor the system’s implementation.

CMS Advances Demonstration to Waive MIPS Requirements for Clinicians in Certain At-Risk Medicare Advantage Plans


Centers for Medicare & Medicaid Services

PRESS RELEASE

FOR IMMEDIATE RELEASE
June 29, 2018 
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries 
                     
CMS Advances Demonstration to Waive MIPS Requirements for Clinicians in Certain At-Risk Medicare Advantage Plans
Today, the Centers for Medicare & Medicaid Services (CMS) is advancing the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration, which, when approved and adopted, would waive Merit-Based Incentive Payment System (MIPS) requirements for clinicians who participate sufficiently in certain Medicare Advantage plans that involve taking on risk. CMS seeks public comment on the information collection burdens associated with the demonstration, which is under consideration for formal approval.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides clinicians with two tracks for payment under Fee-for-Service Medicare:  MIPS, which requires clinicians to report quality data to CMS and have their payment adjusted accordingly; and Advanced Alternative Payment Models (Advanced APMs), which require clinicians to take on risk for their patients’ healthcare spending.
Some Medicare Advantage plans are developing innovative arrangements that resemble Advanced APMs.  However, without this demonstration, physicians are still subject to MIPS even if they participate extensively in Advanced APM-like arrangements under Medicare Advantage.
“The MAQI Demonstration aligns with the Agency’s goal of moving to a value-based healthcare system, and aims to put Medicare Advantage on a more equal playing field with Fee-for-Service Medicare,” said CMS Administrator Seema Verma. “CMS intends to test whether MIPS exemptions provided to clinicians under MAQI will increase participation in Medicare Advantage plans that are similar to Advanced APMs, and thereby accelerate the transition to a healthcare system that pays for value and outcomes.”
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Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter CMS Administrator @SeemaCMS@CMSgov, and @CMSgovPress.



Warrior wellness

Older Veterans with PTSD take part in exercise program aimed at easing symptoms
April 25, 2018
By Mike Richman
VA Research Communications
"When I spoke with Veterans, they stated this is something they wanted—to be offered programs that didn’t focus exclusively on their PTSD diagnosis and that emphasized wellness."
It’s no secret that regular exercise is essential to maintaining a healthy lifestyle and is recommended for everyone, including elderly adults. For people with PTSD, research looking at exercise has shown benefits to quality of life and physical well-being.
But it’s unclear whether working out impacts PTSD symptoms, specifically. And little research has focused directly on the benefits of exercise on older people with PTSD, including Veterans, according to Dr. Katherine Hall, a research health scientist at the Durham VA Health Care System in North Carolina.
Hall thus launched a pilot study to learn if increased physical activity among older Vets with PTSD will help ease their symptoms. Veterans with PTSD have been shown to have low rates of exercise, and many report that they don’t work out at all.
The heart of the study is a supervised 12-week exercise plan called the “Warrior Wellness” program. It consists of activities focusing on strength, flexibility, balance, and endurance training.
Hall and her colleagues created Warrior Wellness to see if older Veterans with PTSD will participate in and benefit from a moderate-to-vigorous workout routine. It differs from other programs because it tailors to Vets with PTSD symptoms, while including elements of peer support, exercise supervision, and repetition. Part of what makes the program special is its extensive exercise battery that can be adapted to individual musculoskeletal ailments.
“We know that PTSD is linked to adverse health outcomes,” says Hall, who is in the Geriatric Research, Education, and Clinical Center at the Durham VA. “And among older Veterans, some of whom have lived with this condition for decades, we see evidence of accelerated aging. The benefits of exercise on physical and emotional health are well-known. Yet, little research has been done on connecting Veterans with mental health conditions to health-promotion programs. When I spoke with Veterans, they stated this is something they wanted—to be offered programs that didn’t focus exclusively on their PTSD diagnosis and that emphasized wellness.”
Psychotherapies may present barriers for older adults  
Hall is also an assistant professor of medicine at Duke University in Durham. She says evidence-based psychotherapies for PTSD, such as prolonged exposure (PE) and cognitive processing therapy (CPT), are effective. But there are sometimes barriers to undertaking and completing those types of treatments, especially among older adults, she says.
The barriers include stigmas relating to mental health services and skepticism about whether the psychotherapies will be effective.
“Lifestyle interventions like exercise may present an opportunity to meet patients where they are and aren’t contingent on mental health treatment,” Hall says. “They also offer patients a chance to engage in activities that are familiar to them and that they enjoy. They promote physical and psychological well-being.”
Fifty-four Veterans with diagnosed cases of PTSD enrolled in the pilot study, which is expected to wrap up this summer. About two-thirds were randomized to the Warrior Wellness program. The rest are in the control group, in which the Vets are free to pursue existing VA health initiatives, such as the MOVE! Weight Management Program.
Participants in the study are at least 60 years old, and almost all of them are men. To be included, they had to use the Durham VA for their primary care.
Hall chose to study older Veterans with PTSD, instead of a younger Veteran cohort, because of their greater susceptibility to functional impairments and chronic health conditions.
“The average age of all Veterans is 58, and the 65-plus age group is the fastest-growing segment of the Veteran population,” she says. “When I first started down this path looking at PTSD and health, I was alarmed by reports showing a link between PTSD and early onset of chronic health conditions, biologic dysregulation, and poor self-care. If we acknowledge that for many of those who suffer PTSD it’s a chronic condition that people live with for decades, then we need to consider its impact in the context of aging. Older Veterans with PTSD are showing up on our door more deconditioned and more frail than older Veterans without PTSD, largely due to a lack of exercise. There are efforts targeting younger Veterans of more recent conflicts. But health promotion programs that address the physical and psychological needs of older Veterans continue to lag behind.”
The Warrior Wellness classes are held at a gym about a mile from the Durham VA. They align with standards of the American College of Sports Medicine, which is dedicated to advancing scientific research as it applies to exercise science and sports medicine. There are three classes per week, about 90 minutes each at most.
The instructors are trained exercise physiologists who are experienced working with older adults. They must be educated in musculoskeletal limitations and chronic disease responses to exercise, knowing that “we’d have a lot of people with hypertension and diabetes, as well as shoulder, knee, and hip injuries that stem from their military service,” Hall says. Anywhere from four to 10 Veterans are working out at the same time.
The exercises gradually become more difficult and intense during the 12-week program, depending on the participant. They target strength (e.g., squat, chest press), balance (e.g., heal-toe walk, single-led stand), flexibility (e.g., standing hamstring and calf stretch) and cardio (e.g., treadmill walking, recumbent cycling).
Hall explains that most of the Vets work one-on-one with instructors for the first two weeks, saying it takes about six sessions for them to gain confidence and understand the correct exercise and breathing techniques. The Veterans are encouraged to exercise independently over the last 10 weeks, with limited guidance and feedback from instructors.
The researchers are hoping to learn about changes in PTSD symptoms, physical function, and cardiovascular endurance. At the end of the 12-week program, the participants complete a checklist that reflects the state of their symptoms. Physical function is assessed using performance tests, and cardiovascular endurance is graded with a timed walking test.
Hall and her team hypothesize that the Vets will improve in these measurements, compared with Veterans in usual care.
She says some of the Veterans “arrived on our doorstep in really bad shape,” but “I’ve been amazed by their physical and psychological transformations over the 12 weeks.” All of the graduates have rated Warrior Wellness “good” or “excellent,” and more than 85 percent are expected to complete the program, which is “fantastic,” she adds.
“Both of those numbers suggest we are offering Veterans a program that is valued and impactful,” she says. “Traditional PTSD treatments are limited by low levels of engagement in older adults, so we were [astonished] to see a response rate of 24 percent among Vets we contacted to participate.”
Some patient testimonials are as follows:
·         “Before this program, I checked my blood sugar once per month, if that. Now I check it every day twice a day.”
·         “I have been going downhill the last couple of years, maybe even longer. With this program, my depression is better. I wake up with a goal. I am able to do projects I haven't done in years.”
·         “This is one of the best programs I have been in through VA.”
·         “A lot of Veterans like me need a program like this to prevent complacency and promote comradeship.”
While the preliminary results look promising, Hall’s team has yet to analyze the impact of the program on PTSD symptoms, such as depression and irritability.
Air Force Vet finds camaraderie in program
The core components of Warrior Wellness are derived from the Social Cognitive Theory (SCT), which is the view that people learn from their experiences and by watching others. SCT proposes that a person’s decision to engage in healthy activities, such as exercise or sports, is influenced by his or her attitude, social support, and proximity to exercise facilities.
“Our interviews with older Veterans with PTSD during the development phase of the Warrior Wellness program told us a lot about the thoughts these Veterans have toward exercise,” Hall says. “We also learned about the physical and psychological barriers we would need to address to help these Veterans be successful in changing their behavior.”
She adds: “We took this information to develop tailored strategies to address these factors. For example, a key construct in SCT is self-efficacy, or the person’s belief in his or her ability to successfully initiate exercise. This was a main target of Warrior Wellness. We provided opportunities early on in the program for participants to see other Veterans who had PTSD and similar physical limitations successfully engaging in the program. Our approach to increasing the duration and intensity over the 12 weeks helped build feelings of mastery.”
Air Force Vet James Richmond, who completed the program last year, appreciated the camaraderie and peer support he absorbed being in the company of other Veterans facing similar challenges.
“It was good being part of a group that could understand,” he says. “I had gone to a civilian doctor, a primary doctor, and he didn’t understand what I was talking about. But Katherine and her group seem to be on top of what I needed to help motivate me and stimulate my interests. They were showing that this would benefit me, and I began to feel like, `I don’t want to miss this. I think I’ll go back.’ I went back day after day, and then it became a week and another week.”
Hall hopes if the results speak highly of Warrior Wellness, VA will consider implementing it in its medical centers. She’s interested in learning whether she can give it a more “hybrid” design, whereby Veterans participate in a facility-based portion and also exercise on their own outside of the gym setting. She plans to pursue a larger clinical study to gain a more definitive look at the program.
“I’m also excited about the opportunities that might exist for integrating exercise into mental health treatment plans for PTSD as a whole-body adjunctive therapy,” she says. “In addition to implementing this particular type of program, though, I’m hoping that the results may impact the culture of VA and care practices.
“I hope our study will underscore that PTSD, and Veterans who have had it on their `active problems’ list for many years, are not intransigent. That they are not incapable of making changes to improve their own health. We need to offer patient-centered programs that target outcomes of interest to these patients. We also need to make sure Veterans with psychological conditions like PTSD are not excluded from participating in these programs. Supervised exercise fits that bill.”
https://www.research.va.gov/currents/0418-Older-Veterans-with-PTSD-take-part-in-exercise-program.cfm