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Monthly Archives: April 2016

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First Edition: April 29, 2016

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FAQ: Medicare Lays Out Plans For Changing Doctors’ Pay

Federal officials have unveiled their roadmap to a revamped Medicare physician payment system designed to reward doctors and other clinicians for the quality of care delivered, rather than the quantity.

The proposed regulation would replace a patchwork of programs that now govern physician payments in Medicaid. It would allow doctors to choose from a new menu of measures and activities that officials said would be tailored to the type of care clinicians provide in Medicare’s traditional fee-for-service program.

“By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care and give them the opportunity to participate in a way that is best for them, their practice and their patients,” said Patrick Conway, acting principal deputy administrator and chief medical officer at the Centers for Medicare & Medicaid Services (CMS), the federal agency that is implementing the new physician payment program.

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Currently doctors are paid for things like tests, treatments and other procedures, but not necessarily for spending time with patients to learn more about their health or develop a treatment plan. Officials say the new payment program will change that.

With wide bipartisan support, Congress last year voted to scrap the existing Medicare physician payment formula and transition to a new system focused on quality, value and accountability. Here are some questions and answers about the newest phase of this effort.

Q: What is the government offering?

A: The proposed regulation would create two new payment systems. One, called the “merit-based incentive payment system,” or MIPS for short, would evaluate the value and quality of care on four performance categories: cost, quality, how doctors use electronic health record technology in their daily practice and share that information with other providers, and activities that improve care, such as care coordination or how much beneficiaries are engaged in their care. That composite score is used to determine a positive, negative or no adjustment to a provider’s Medicare Part B payment for a medical service.

The second system for doctors sets payments through “advanced alternative payment models” or advanced APMs. Under these models, clinicians accept more risk — and could also make more money — for providing coordinated, high-quality care, according to CMS. Examples include efforts to create a centralized “medical home” in which a team of health professionals provide coordinated care to improve patients’ health, and newer models of accountable care organizations in which doctors, hospitals and other health care providers form networks that work together to help improve the quality and reduce the spending for patient care.

CMS officials expect that most Medicare clinicians will initially participate in the MIPS program but over time will move more toward the alternative payment models.

Q: Who will get paid this way?

doctor medicare payA: Most doctors that treat patients in the traditional Medicare program, as well as other clinicians, such as physicians assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, that also provide care to Medicare beneficiaries, will be paid under either the MIPS or advanced APMs system. Clinicians can be exempted from MIPS if they are new to Medicare, have less than $10,000 in Medicare charges or see 100 or fewer Medicare patients or are “significantly participating” in an advanced APM.

Q: Why is this happening now?

A: As part of legislation Congress passed last year to overhaul the Medicare physician payment system, CMS had to publish a plan by May 1 that detailed how it would measure physician quality under the new system. Doctors and other interest groups can now comment on the proposal until June 26, and CMS is expected to issue a final rule this fall.

Q: What happens next?

A: Under the law setting up the changes in payment, physicians will receive a fee increase of 0.5 percent per year between 2016 and 2019 as the new system is developed and put into place. In񎧡, Medicare will begin measuring performance for doctors and other clinicians for the MIPS program, with payments based on those measures beginning in 2019. Under that system, payments generally won’t increase or drop by more than 4 percent, rising gradually to 9 percent from 2022 and beyond. Doctors can earn additional bonuses for exceptional performance.

Practitioners who pursue APMs would qualify for a 5 percent Medicare Part B incentive payment for the years 2019 through 2024.

Q: Does this mean that Medicare beneficiaries will pay more to see their doctors?

A: No. Medicare Part B premiums, which cover visits to a physician and other outpatient services, are set by law and adjusted yearly. Once the Part B deductible is met, beneficiaries usually cover 20 percent of the amount Medicare pays, or purchase a supplemental policy that can pick up much of that cost.

Q. How did the doctor payment formula become an issue?

A: The prior physician payment system, which was called the sustainable growth rate or SGR, was created in a 1997 deficit reduction law, a broader legislative effort to control federal spending. For the first few years, Medicare expenditures did not exceed the target in that law and doctors received modest pay increases. But in 2002, doctors were furious when their payments were reduced by 4.8 percent. Every year since, Congress has staved off the scheduled cuts. But each deferral just increased the size of the fix needed the next time. Last year, lawmakers finally agreed to cut a deal for repeal and move on.

Q: What’s been the reaction to the new physician payment proposal?

A: Doctor and physician groups appear to be on board so far and a few lawmakers in both parties also have expressed support. All pledge to continue to monitor the process.

In a statement, the president of the American Medical Association, Dr. Steven J. Stack, said the group’s “initial review suggests that CMS has been listening to physicians’ concerns” in particular by modifying federal rules concerning physicians and electronic health records and reducing burdens on quality reporting. The new system, Stack said, “needs to be relevant to the real-world practice of medicine and establish meaningful links between payments and the quality of patient care, while reducing red tape.”

Robert Berenson, a fellow at the Urban Institute, said a key question for the law is “have they set it up so small practices can actually stay in business and report so they don’t have to throw in the towel and get hired by somebody because the reporting burden is too great?” Berenson, who has been critical of the new Medicare physician payment law, is a member of a technical advisory committee created in the law to evaluate its implementation.

Paul B. Ginsburg, who serves as director of the Center for Health Policy at the Brookings Institution and is also director of public policy at the Schaeffer Center at the University of Southern California, said the proposed rule gives physicians a lot of flexibility in choosing how they are rated under the MIPS program but is more restrictive on what qualifies as an APM.

Payment increases under either system may not be generous enough to keep up with other costs, such as increases in practice expenses. “This is better than a 20 percent cut (under the old system) but in a sense it means that the very severe constraint on physician payment is going to continue for some time,” he said.

Q: Where can I read more about this new plan?

A: CMS has published a web page, a fact sheet and a video to explain the proposal.

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HHS Acts To Help More Ex-Inmates Get Medicaid

Administration officials moved Thursday to improve low Medicaid enrollment for emerging prisoners, urging states to start signups before release and expand eligibility to thousands of former inmates in halfway houses near the end of their sentences.

Health coverage for ex-inmates “is critical to our goal of reducing recidivism and promoting the public health,” said Richard Frank, assistant secretary for planning for the Department of Health and Human Services.

Advocates praised the changes but cautioned that HHS and states are still far from ensuring that most people leaving prisons and jails are put on Medicaid and get access to treatment.

“It’s highly variable. Some states and jurisdictions are having a lot of success” enrolling ex-prisoners, said Kamala Mallik-Kane, a researcher at the Urban Institute who has studied the process. “Others of them have initiatives in place that aren’t reaching the kinds of numbers that are making a dent.”

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The 2010 health law made nearly all ex-prisoners eligible for Medicaid in states that chose to expand the state and federal insurance program for the poor. Many welcomed the chance to cover a group with high rates of chronic disease, mental illness and substance abuse problems.

But prisons and jails, burdened with ineffective computers, understaffing and complicated Medicaid enrollment procedures, have been slow to sign up released inmates.

Federal and state prisons let out more than 600,000 people a year. Millions more cycle through jails. But a study published in Health Affairs found prisons and jails nationwide enrolled only 112,520 emerging inmates between late 2013 up to January 2015.

In Maryland, often cited for progressive social policy, the prison system is enrolling fewer than one in 10 released inmates, Kaiser Health News reported this week.

Much of HHS’ guidance repeats existing policy, reminding states that those on probation or parole are eligible for Medicaid and urging states to keep prisoners’ names in the Medicaid computers while they’re locked up. (That eases re-enrollment.)

Inmates are generally ineligible for Medicaid while incarcerated. Prison and jail medical systems care for them.

HHS is “providing encouragement and a nudge” to states to improve sign-ups as well as money to upgrade enrollment computers, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied ex-inmate enrollment. “They understand that this is a technology issue.”

Making up to 96,000 halfway-house inmates eligible for Medicaid is new policy, designed to connect people with care before they’re fully released. Prisoners often move to halfway houses or home detention near the end of their terms, closely supervised but frequently allowed to shop, apply for jobs and see a doctor.

Under the new policy, “if you have a fair amount of freedom of movement” in a halfway house, “you’re not considered an inmate” for Medicaid purposes, said Sarah Somers, an attorney for the National Health Law Program, an advocacy group. “That will be very helpful for a lot of people who are trying to transition out of incarceration.”

Nathan Sharpe recently spent two months in a home detention program in West Baltimore between leaving prison and being fully released. He wanted to get a checkup to make sure there was no lasting damage from a stabbing he received last summer in Maryland’s Jessup Correctional Institution.

But he had to wait until home detention ended last week to be covered by Medicaid, he said.

“That helps a lot” if people like him could get on Medicaid after they first leave prison, he said. “People can get the health care they need sooner. I’ve been out a week now and I still haven’t been able to see a doctor because I don’t have my card.”

Ex-inmates have extremely high rates of HIV and hepatitis C infection, diabetes, mental illness and substance abuse problems. They are especially vulnerable after they leave the prison medical system and before they connect with community doctors.

One study in Washington state showed that ex-inmates were a dozen times more likely to die than the general population in the first two weeks after their release.

Immediate Medicaid coverage “can mean the difference between life in the community and recidivism and even life and death,” Michael Botticelli, the White House’s director of national drug control policy, told reporters.

HHS has been urging states to enroll ex-inmates in Medicaid for years. But the Affordable Care Act’s Medicaid expansion made many more of them eligible for coverage, giving policymakers a new reason to promote sign-ups, advocates said.

So far 31 states and the District of Columbia have expanded Medicaid under the law.

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Even As Birth Rates Fall, Teens Say They Are Getting Less Sex Education

Teenage girls are catching up to teenage boys in one way that does no one any good: lack of sex education, according to a recent report.

The proportion of teenage girls between the ages of 15 and 19 who were taught about birth control methods declined from 70 to 60 percent over two time periods, from 2006-2010 and 2011-2013, the analysis of federal data found. Meanwhile, the percentage of teenage boys in the same age group who were taught about birth control also declined, from 61 to 55 percent.

“Historically there’s been a disparity between men and women in the receipt of sex education,” said Isaac Maddow-Zimet, a coauthor of the study and a research associate at the Guttmacher Institute, a reproductive health research and advocacy group. “It’s now narrowing, but in the worst way.”

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The study, which was published online in the Journal of Adolescent Health in March, analyzed responses during the two time periods from the Centers for Disease Control and Prevention’s National Survey for Family Growth, a continuous national household survey of women and men between the ages of 15 and 44.

In addition to questions about birth control methods, the study asked teens whether they had received formal instruction at their schools, churches, community centers or elsewhere about sexually transmitted diseases (STDs), how to say no to sex or how to prevent HIV/AIDS.

A rear view image of a high school classroom with teenagers learning science and chemistry.

Overall, 43 percent of teenage girls and 57 percent of teenage boys said in the most recent time frame that they hadn’t received any information about birth control before they had sex for the first time.

The proportion of young women who said they had been taught about how to say no to sex declined from 89 to 82 percent over the two study periods. For young men, the proportion remained essentially unchanged, inching up to 84 from 82 percent.

There were slight declines in the proportions of young women and men who said they had been taught about STDs and HIV/AIDS, but the responses were above 85 percent during both study periods for both sexes.

Teens talked with their parents to varying degrees about birth control and STDs. However, 22 percent of young women and 30 percent of young men said they didn’t talk with their parents about any of the topics.

The study also notes that the decline in formal education about birth control occurred even though the federal government spending has increased for teen pregnancy prevention programs.

Despite the lack of formal teaching, teenage pregnancy rates have declined for more than two decades and are now at historic lows. Racial disparities remain, however, and few teens use highly effective long-acting contraceptives such as intrauterine devices or hormonal implants.

“Even though the teen pregnancy rate is declining, it might decline faster if teens were getting sex education,” Maddow-Zimet said.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

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Pregnant Women In Houston And Their Doctors Weigh Risks Of Zika

As summer approaches, anxiety about Zika is growing in states like Florida and Texas. The virus hasn’t spread to mosquitoes along the Gulf Coast, and it may not, but experts are preparing nonetheless.

And because Zika can cause birth defects in newborns, many women — and their doctors — are nervous. In the waiting room at Houston IVF, patients are handed a map of Zika-affected countries and asked to fill out a questionnaire.

“The first thing I’m discussing now is Zika,” said Dr. Jamie Nodler.

Public health officials said there have been 15 travel-related incidences of Zika in the Houston area. Nodler said at least a few couples have had to delay starting fertility treatment because the woman or her partner already may have been exposed to the virus while traveling south.

This map shows the predicted distribution of Aedis aegypti, the mosquito that can carry the Zika virus. The redder the area, likelier you are to find A. aegypti there. (Courtesy Kraemer et al., eLife)

This map shows the predicted distribution of Aedis aegypti, the mosquito that can carry the Zika virus. The redder the area, likelier you are to find A. aegypti there. (Courtesy Kraemer et al., eLife)

“Especially in Houston a lot of our patients and families are in the oil and gas industry,” Nodler said. “These aren’t people who are traveling to Mexico and Puerto Rico for fun or vacation. These are people who have to work in some of these offshore drilling areas.”

Even for patients who haven’t traveled, Nodler is advising they slather on repellant, just in case the virus is already here, but we don’t know it yet.

“No one wants to see an affected child,” he said.

Nodler says couples will need to manage Zika risk together. If his partner is already pregnant, a man should use condoms to avoid sexually transmitting the virus.

All over the city, parents and would-be parents have been absorbing the news about Zika.

This story is part of a partnership that includes Houston Public Media, NPR and Kaiser Health News. It can be republished for free. (details)logo npr

“They’ve been saying Zika is coming to Houston, they don’t know when,” said Annie Tursi. She’s 35, owns four hair salons and her husband is a consultant. She said they were going to try for a third baby in 2016, but now they’re going to watch and wait.

“I think we’re really blessed to have two healthy boys, and if it does come this summer and it is a risk, then I probably just won’t even try for another one.”

Between their jobs and the toddler and the baby, there’s no way she can simply hunker inside all summer avoiding mosquitoes.

“Right now there’s just so many unknowns and I think by the time they have a vaccine and know more that we’ll be done” with having children, she said, chuckling. “We’ll be out of diapers and we’ll be done.”

Because of concerns about Zika, Annie Tursi and her husband Brian are rethinking plans to try for a third child in 2016. Here with Oliver (2) and Arthur (6 months). (Courtesy Annie Tursi)

Because of concerns about Zika, Annie Tursi and her husband Brian are rethinking plans to try for a third child in 2016. Here with Oliver (2) and Arthur (6 months). (Courtesy Annie Tursi)

Another Houston mom, Tracy Smith, couldn’t make that choice. She was already pregnant with twins when she heard about Zika. At a recent check-up, she learned she still had to be cautious even though her first trimester was over.

“She said it’s something to be concerned about your whole pregnancy you need to be in long sleeves, and long pants, wearing DEET,” said Smith, who was shocked to get that advice.

“My first thought was ‘I’m pregnant, I’m not going to put DEET all over myself!’ But I guess that’s what we do this summer,” she said.

She’s now wondering if she and her two other kids should move to her parent’s house for the summer, in a less buggy part of Houston.

“The probability is low,” that she’ll contract Zika, she said, “But the potential impact is so great and those are the kinds of threats that can be scary and disproportionately sort of taking up space in my brain.”

Health officials say because U.S. cities have a lot of closed spaces with air conditioning or screens, people are generally better shielded from mosquitoes than in some other countries.

Nonetheless, doctors in Houston have already opened a special clinic where women who have traveled to affected countries can get blood tests and counseling. A second clinic will open this summer.

Dr. Kjersti Aagaard, a professor at Baylor College of Medicine, said doctors are offering those clinic patients an ultrasound 15 weeks into pregnancy.

“We’ve actually developed a protocol around looking for very special views of the fetal brain and the eyes to look at for any evidence of fetal malformation with the Zika.”

Dr. Kjersti Aagaard, an associate professor of obstetrics and gynecology at Baylor College of Medicine, is helping screen pregnant women in Houston who may have been exposed to Zika through travel or a partner who has traveled to affected areas. (Courtesy Baylor College of Medicine)

Dr. Kjersti Aagaard, an associate professor of obstetrics and gynecology at Baylor College of Medicine, is helping screen pregnant women in Houston who may have been exposed to Zika through travel or a partner who has traveled to affected areas. (Courtesy Baylor College of Medicine)

Aagaard reminds her patients that Zika is just one of many possible risks during pregnancy — and risks can be managed, whether that’s through prenatal vitamins, genetic screening, or bug spray.

Zika is tough to talk about, though, because the studies are just not there yet.

“As much as we wish we could give them a very set of clear facts around: this is your risk, this is the time in pregnancy you’re at highest risk, or this is the time prior to planning a pregnancy you’re at highest risk. We simply don’t have that information,” she said. “We don’t know.”

Despite the unknowns, doctors in Houston aren’t telling people not to get pregnant.

What they are telling them is that they need to add mosquito bites to the list of cares and calculations that surround any pregnancy.

This story is part of a reporting partnership with NPR, Houston Public Media and Kaiser Health News.

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Longer Looks: Madness, The Robot Revolution and Traumatic Births

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Viewpoints: Finding Profits With Obamacare; Entitlement Reform And The 2016 Election

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State Highlights: Gov. Dayton Creates Minn. Mental Health Task Force; Affordability, Access Key Issues At Fla. Summit

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Mo. Lawmakers Pass Bill Aimed At Preventing ‘Double-Dipping’ On Medical Costs In Courts

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