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DHS Explains Latest Medicaid Initiatives

pa dhsThe Pennsylvania Department of Human Services describes two recent steps to improve the delivery of health care to low-income Pennsylvanians – the introduction of its new “Community HealthChoices” program and the re-bidding of managed care organization contracts for its HealthChoices physical health program – in the latest edition of its newsletter The Impact.
Find that edition here.

2015-09-29T06:00:21+00:00September 29th, 2015|HealthChoices PA, Pennsylvania Medicaid policy|Comments Off on DHS Explains Latest Medicaid Initiatives

PA Puts New HealthChoices Contracts Up for Bid

The Pennsylvania Department of Human Services (DHS) has issued a request for proposals (RFP) for organizations interested in serving the state’s Medicaid population through its HealthChoices Medicaid managed care program.
The HealthChoices program, introduced in 1997, currently serves nearly 2.5 million Pennsylvanians. Among them, 200,000 have enrolled in the program since the state’s Medicaid expansion began in January.
healthchoicesThe contracts will put a greater emphasis on value-based purchasing and will require participating insurers to provide at least 30 percent of their services in a value-based or outcomes-based manner within three years.  Among the tools managed care organizations are expected to employ to achieve this goal are accountable care organizations, bundled payments, and patient-centered homes.
With a projected value of about $17 billion, the RFP is expected to attract interest from national organizations that have not necessarily served Pennsylvania’s Medicaid population in the past.
To learn more about the state’s HealthChoices plans, see this news release from the Department of Human Services and this Philadelphia Inquirer article. Find the RFP itself here.

2015-09-23T06:00:50+00:00September 23rd, 2015|HealthChoices PA, Meetings and notices|Comments Off on PA Puts New HealthChoices Contracts Up for Bid

Medicare Readmissions Program Unfair to Safety-Net Hospitals, Study Finds

Medicare’s readmissions reduction program penalizes hospitals based largely on the patients they serve rather than their performance serving them, a new study has concluded.
According to the report “Patient Characteristics and Differences in Hospital Readmission Rates,” published in the journal JAMA Internal Medicine,

Patient characteristics not included in Medicare’s current risk-adjustment methods explained much of the difference in readmission risk between patients admitted to hospitals with higher vs lower readmission rates. Hospitals with high readmission rates may be penalized to a large extent based on the patients they serve.

Among those two dozen socio-economic factors: patient income, education, and ability to bathe, dress, and feed themselves.
jama internal medicineThe study found, for example, that the worst-performing hospitals under Medicare’s hospital readmissions reduction program have 50 percent more patients with less than a high school education than the program’s best performers.
Pennsylvania’s safety-net hospitals serve especially large numbers of low-income patients and have been especially vulnerable to the readmissions reduction program’s penalties.
To learn more about the study, see this Washington Post story. To find the study itself, go here, to the web site of JAMA Internal Medicine.

2015-09-22T06:00:25+00:00September 22nd, 2015|Medicare|Comments Off on Medicare Readmissions Program Unfair to Safety-Net Hospitals, Study Finds

PA to Push for Value-Based Purchasing of Care

The Secretary of Pennsylvania’s Department of Health has issued a call for greater use of value-based purchasing of health care services in the state.
department of healthAt a conference hosted by the Pittsburgh Business Group on Health, Secretary Karen Murphy invited insurers and employers to work together to pursue a value-based approach to the purchase of health care that would reduce the cost of care while improving the results of the care patients receive.
To support this initiative, Secretary Murphy has created a new innovation center in the state’s Health Department and appointed a deputy secretary to lead this effort.
Learn more about the state’s intentions in this Pittsburgh Business Times article.
 

2015-09-18T06:00:48+00:00September 18th, 2015|Uncategorized|Comments Off on PA to Push for Value-Based Purchasing of Care

DHS Issues RFI for Vendors to Help Monitor Payments

Pennsylvania’s Department of Human Services (DHS), which administers the state’s Medicaid program, is seeking information from vendors that offer data mining and predictive analytics that might help the state monitor Medicaid and other payments.
pa dhsDHS seeks to use such services to “…detect patterns of waste, fraud, and abuse in its programs on a prospective or retrospective basis.”
Among the challenges such vendors might address in their responses, as stated in the RFI, are:

  • Identifying claim review strategies that efficiently and proactively prevent or address potential errors (e.g., prepayment edit specifications or parameters).
    Providing mechanisms to investigate patterns that may indicate abuse of services by clients.
  • Producing innovative views of utilization or billing patterns that illuminate potential errors.
    Maximizing recoveries by identifying high volume or high cost services that are widely over utilized.
  • Identifying areas of potential errors (e.g., services which may be non-covered or not correctly coded) that poses the greatest risk or vulnerability.
    Establishing baseline data to enable DHS to dynamically recognize unusual trends, changes in utilization over time, or schemes to inappropriately maximize reimbursement. Adapting systems, rules, and algorithms on an ad hoc basis in order to be responsive to emerging trends, patterns, and issues as they are identified.
  • Clearly distinguishing which applications are standardized as part of the product package and which applications will need to be purchased as a system enhancement.
  • Establishing baseline data and recommendations to improve the client experience related to access to services and the quality of the services received.

The call for vendors is a request for information (RFI) and not a request for proposals (RFP) but it appears likely that the state will issue an RFP after it has had an opportunity to review the information submitted to it.
RFI submissions are due on November 9. See the RFI document here.

2015-09-17T06:00:51+00:00September 17th, 2015|Meetings and notices|Comments Off on DHS Issues RFI for Vendors to Help Monitor Payments

MedPAC Looks at Various Issues at September Public Meeting

The independent federal agency that advises Congress on Medicare payment issues held its monthly public meeting in Washington, D.C.
medpacDuring the two days of meetings, the Medicare Payment Advisory Commission (MedPAC) discussed its work on six specific issues:

  • developing a unified payment system for post-acute care
  • a preliminary analysis of Medicare Advantage encounter data for Part B services
  • factors affecting variation in Medicare Advantage plan star ratings
  • Medicare drug spending
  • emergency department services provided at stand-alone facilities
  • payments from drug and device manufacturers to physicians and teaching hospitals

Each discussion was accompanied by an issue brief and a presentation; find those documents here.

2015-09-16T06:00:54+00:00September 16th, 2015|Medicare|Comments Off on MedPAC Looks at Various Issues at September Public Meeting

Medicare Proposes Addressing Health Disparities

The Centers for Medicare & Medicaid Services (CMS) has unveiled its first plan to reduce health disparities among Medicare beneficiaries.
The plan, produced by CMS’s Office of Minority Health and titled “The CMS Equity Plan for Improving Quality in Medicare,” will seek to improve care for

…Medicare populations that experience disproportionately high burdens of disease, lower quality of care, and barriers to accessing care. These include racial and ethnic minorities, sexual and gender minorities, people with disabilities, and those living in rural areas.

Prescription Medication Spilling From an Open Medicine BottleThis is the very population served in disproportionate numbers by many of Pennsylvania’s private safety-net hospitals.
The program will focus on six priorities:

  • expanding the collection, reporting, and analysis of standardized data
  • evaluating disparity impacts and integrating equity solutions across Medicare programs
  • developing and dissemination promising approaches to reducing health disparities
  • increasing the ability of the health care workforce to meet the needs of vulnerable populations
  • improving communication and language access for individuals with limited English proficiency and persons with disabilities
  • increasing physical accessibility of health care facilities

To learn more about The CMS Equity Plan for Improving Quality in Medicare, see this CMS news release.

2015-09-15T06:00:58+00:00September 15th, 2015|Medicare, Pennsylvania safety-net hospitals|Comments Off on Medicare Proposes Addressing Health Disparities

PA Insurance Commissioner to Hold Hearing on Balance Billing

insurance deptPennsylvania Insurance Commissioner Teresa Miller will hold a public hearing next month to begin exploring the practice of balance billing.
According to a department news release, the hearing will

…be an opportunity to begin exploring options to make sure consumers are informed about their care and do not face these unexpected bills without recourse, as well as to identify some possible consumer-friendly solutions to the issue. Miller believes this hearing will be a substantive first step in tackling the issue of balance billing, and giving consumers more peace of mind and predictability in coverage.

The hearing will be held on October 1 in Harrisburg.
For more information about balance billing and the issues the Insurance Department hopes to begin addressing at this hearing, see this news release.
 

2015-09-14T06:00:37+00:00September 14th, 2015|Uncategorized|Comments Off on PA Insurance Commissioner to Hold Hearing on Balance Billing

PA Included in New Medicare Value-Based Insurance Program Demonstration

Pennsylvania is one of seven states that will participate in a new value-based purchasing demonstration program for Medicare Advantage plans.
cmsAccording to a fact sheet published by the Centers for Medicare & Medicaid Services (CMS),

Value-Based Insurance Design (VBID) generally refers to health insurers’ efforts to structure enrollee cost sharing and other health plan design elements to encourage enrollees to use high-value clinical services – those that have the greatest potential to positively impact enrollee health. VBID approaches are increasingly used in the commercial market, and evidence suggests that the inclusion of clinically-nuanced VBID elements in health insurance benefit design may be an effective tool to improve the quality of care while reducing its cost for Medicare Advantage enrollees with chronic diseases. As part of the “better care, smarter spending, healthier people” approach to improving health care delivery, CMS will test VBID in Medicare Advantage and measure whether structuring patient cost sharing and other health plan design elements does encourage enrollees to use  health care services in a way that reduces costs.

According to CMS,

The MA-VBID model supports high-value clinical services, improved health outcomes, and health care cost savings or cost neutrality through the use of structured patient cost sharing and other health plan design elements that encourage enrollees to use high-value clinical services. The MA-VBID model will provide flexibility for Medicare Advantage plans accepted into the model to develop clinically-nuanced benefit designs for enrollee populations that fall within certain clinical categories.

The clinical conditions on which the program will focus are diabetes, chronic obstructive pulmonary disease, congestive heart failure, patients who have suffered strokes, hypertension, coronary artery disease, and mood disorders.
The program, to be launched in January of 2017, will run for five years in seven states: in addition to Pennsylvania, Medicare Advantage plans in Arizona, Indiana, Iowa, Massachusetts, Oregon, and Tennessee will be invited to participate.
To learn more about Medicare’s new Value-Based Insurance Design programs, see this CMS news release and fact sheet.
 

2015-09-11T06:00:03+00:00September 11th, 2015|Medicare|Comments Off on PA Included in New Medicare Value-Based Insurance Program Demonstration

Newspaper Profiles DHS Secretary

ted dallasThe Pittsburgh Post-Gazette has published a profile of Pennsylvania Department of Human Services Secretary Ted Dallas. His department and its Office of Medical Assistance Programs administers the state’s Medicaid program.
Find that profile here.

2015-09-10T06:00:52+00:00September 10th, 2015|Uncategorized|Comments Off on Newspaper Profiles DHS Secretary
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