Affordable Care Act Archives - Page 5 of 15 - Safety-Net Association of Pennsylvania

PA Medicaid: One Year, 625,000 New Beneficiaries

Last week marked the one-year anniversary of Pennsylvania’s Affordable Care Act-authorized expansion of its Medicaid program.
In that year, nearly 625,000 Pennsylvanians enrolled in the program.
Among them,

46 percent are under the age of 35
109,000 are parents
300,000 are employed

pa healthchoices regions
If past Medicaid utilization patterns hold true, most of these new Medicaid beneficiaries will receive most of their health care benefits from the state’s private safety-net hospitals.
Learn more about Pennsylvania’s Medicaid expansion, who has taken advantage of it, and how the program has changed in the past three years in this state news release.

PA Safety Net Admin2016-05-04T06:00:05+00:00May 4th, 2016|Affordable Care Act, Pennsylvania Medicaid, Pennsylvania Medicaid policy, Pennsylvania safety-net hospitals|Comments Off

Safety Net Still Needed, Study Finds

Despite Affordable Care Act policies that have enabled millions of Americans to obtain health insurance, the health care safety net is still needed.
Or so concludes a new report from the Georgetown University Health Policy Institute’s Center on Health Insurance Reforms.
For the report A Tale of Three Cities: How the Affordable Care Act is Changing the Consumer Coverage Experience in 3 Diverse Communities, researchers visited and examined conditions in Tampa, Columbus, and Richmond (Virginia), and among their conclusions was:

We still need a safety net. Safety net programs in existence before the ACA were expected to become less necessary once the ACA coverage expansions took effect. And to some extent that has indeed been the case. But what was deemed affordable under the ACA for those with income too high for Medicaid eligibility is not necessarily perceived to be affordable to the individuals enrolling in the marketplace plans, particularly when health care spending must compete with other pressing household expenses. As a result, safety net providers report that many patients who start the year with coverage return to them later in the year uninsured.

The report also found that

Safety net providers are adapting to the new coverage and health system landscape ushered in by the ACA. However, there’s not yet enough data to know whether coverage has translated to better, more affordable access to health care services.

To learn more about the report and its findings, go here to read a Center on Health Insurance Reforms blog entry on the research and go here to see the report itself.

PA Safety Net Admin2016-04-13T06:00:37+00:00April 13th, 2016|Affordable Care Act, Health care reform|Comments Off

New Approaches to Readmissions Reduction Program?

While Medicare’s readmissions reduction program has produced a decline in the number of Medicare readmissions within 30 days of discharge, critics – among them many safety-net hospitals – argue that the program is unfair to hospitals that serve especially large numbers of low-income patients whose distinct needs pose a greater risk of requiring readmission to address.
In a new report, the journal Health Affairs notes that such arguments have given rise to a number of proposals for possible changes in the readmissions reduction program. Among them, the Medicare Payment Advisory Commission

…has proposed a revision to the method for calculating readmissions. Rather than including patient SES [note: socio-economic status] in the risk-adjustment step, which MedPAC argues would take years to develop empirically and could mask true quality disparities, MedPAC suggests grouping hospitals into peer groups based on their share of low-income Medicare patients and then set readmissions targets for each peer group. Put another way, hospitals with similar shares of low-income patients would be compared with each other instead of all hospitals.

Other suggestions for modifying the readmissions reduction program include shortening the window on readmissions, which might better reflect the quality of care a hospital provides rather than the nature of the patients it serves; changing the quality measures on which hospitals are judged, choosing new measures that might be less sensitive to socio-economic factors; and providing additional financial or other support to hospitals that serve especially large numbers of low-income patients.
To learn more about the kinds of challenges Medicare’s hospital readmissions reduction program pose and what might be done to address them without discarding the program entirely, go here for the Health Affairs article “The Challenges Of Rewarding Value Over Volume Without Penalizing Safety-Net Hospitals.”

PA Safety Net Admin2016-04-07T06:00:04+00:00April 7th, 2016|Affordable Care Act, Medicare|Comments Off

Safety-Net Hospitals’ Readmissions Challenge

The March edition of the journal Health Affairs offers a compelling snapshot of a type of patient many safety-net hospitals serve on an almost daily basis: the “superutilizer” who lacks the ability and resources to address his own medical needs.
The article “Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital” tells the story of a patient who

…had been using drugs and alcohol since his teenage years, and he was addicted to crack cocaine and alcohol…He had been released from prison six months before we first met him, without any basic resources to help him transition back into society – not even a state ID. Lacking this fundamental necessity, he could not apply for state health insurance or a Supplemental Nutrition Assistance Program card to receive food stamps. As an ex-felon with no income, he couldn’t find a place to live. He told us he was living on the streets, where he spent his days panhandling and using the money he got to buy tacos from street vendors and hash browns from McDonald’s.

Mr. G’s first several admissions to our hospital were similar. He would walk into the emergency department, unable to breathe, and would be admitted to the hospital for treatment related to heart failure. He had a complex medical history including diabetes and extremely poor heart function – which was complicated by a clot in his heart that required the chronic use of blood thinners. Furthermore, he suffered from schizophrenia.

The hospital faced a problem in addition to caring for Mr. G.

The problem with Mr. G’s admissions, aside from their drain on hospital resources, is that to motivate hospitals to improve care, Medicare penalizes hospitals for certain patients who are readmitted within thirty days. This policy assumes that all patients have the means and internal resources to care for themselves effectively and that hospitals, by simply adhering to best practices of medical management, can avoid redundant care. Medicare fails to consider the complications imposed by poverty and the significant burden safety-net hospitals face in trying to address overwhelming social issues.

A typical admission was set in motion by Mr. G’s nonadherence to his medications, poor diet, substance abuse, or a combination of the three. With each admission, additional problems and complications cropped up that extended his stay.

The problems continue, and the article explains that

Patients like Mr. G frustrate health care providers. These patients are often dismissed as being nonadherent, and their psychosocial needs go unrecognized. Their daily challenges are compounded by poverty, mental illness, substance abuse, lack of social support, lack of transportation, and unstable housing. These factors – and other social determinants of health – set the stage for poor health outcomes in patients with low socioeconomic status.

The article concludes by noting that

Current health care policy emphasizes the reduction of readmissions but does not support the time and resources needed to achieve this goal. As the basis for payment shifts from volume to value, it will become exceedingly expensive to continue ignoring the social determinants of health.

To learn more about Mr. G, the hospital that served him, and the challenges Pennsylvania’s safety-net hospitals face when serving patients CMS has labeled “superutilizers,” go here, to the web site of the journal Health Affairs, to see the complete article “Mr. G And The Revolving Door: Breaking The Readmission Cycle At A Safety-Net Hospital.”

PA Safety Net Admin2016-04-06T06:00:21+00:00April 6th, 2016|Affordable Care Act, Medicare, Pennsylvania safety-net hospitals|Comments Off

MACPAC Unhappy With How DSH is Dished

Medicaid disproportionate share hospital payments (Medicaid DSH) are not getting to the hospitals that need them most, according to the independent agency that advises Congress and the administration on Medicaid access, payment, and care delivery issues.
In its March 2016 Report to Congress on Medicaid and CHIP, the Medicaid and CHIP Payment and Access Commission found

…little meaningful relationship between DSH allotments and three aspects of DSH payments that Congress asked us to study: 1) the relationship of state DSH allotments to data relating to changes in the number of uninsured individuals, 2) data relating to the amount and sources of hospitals’ uncompensated care costs, and 3) data identifying hospitals with high levels of uncompensated care that also provide access to essential community services for low-income, uninsured, and vulnerable populations.

MACPAC also observed that

Although early reports suggest that the coverage expansions are improving hospital finances in general, it is not yet clear how hospitals that are particularly reliant on Medicaid DSH payments are being affected.

MACPAC further maintains that

…DSH allotments and payments should be better targeted, consistent with their original statutory intent.

Noting an obstacle to such an undertaking, MACPAC

…recommends that the Secretary [of Health and Human Services] collect and report hospital-specific data on all types of Medicaid payments for all hospitals that receive them. In addition, the Secretary should collect and report data on the sources of non-federal share necessary to determine net Medicaid payment at the provider level.

Finally, MACPAC promises to continue looking into this challenge and exploring possible solutions.

In future reports on DSH payment policy, which MACPAC will include in its annual March reports to Congress, the Commission will continue to monitor the ACA’s effect on hospitals receiving DSH payments. We also plan to explore potential approaches to improving targeting of federal Medicaid DSH funding, including modifying the criteria for DSH payment eligibility, redefining uncompensated care for Medicaid DSH purposes, and rebasing states DSH allotments.

To learn more about what MACPAC had to say about Medicaid DSH and other Medicaid- and CHIP-related issues, go here to see the MACPAC report March 2016 Report to Congress on Medicaid and CHIP.

PA Safety Net Admin2016-03-21T06:00:56+00:00March 21st, 2016|Affordable Care Act, Medicaid supplemental payments|Comments Off

Report on One Year of Medicaid Expansion in PA

Taking advantage of the Affordable Care Act, Pennsylvania expanded its Medicaid program a little more than a year ago. Now, Department of Human Services Secretary Ted Dallas reflects on that year, offering statistics on how many people have taken advantage of enhanced access to Medicaid coverage, who those people are, and where they live.
Secretary Dallas also offers his perspectives on how the transition to the expanded Medicaid program went and how the new program differs from the old.
Read Secretary Dallas’s report here, on the Wolf administration’s blog.

PA Safety Net Admin2016-02-12T06:00:38+00:00February 12th, 2016|Affordable Care Act, Pennsylvania Medicaid policy|Comments Off

Push From Volume to Value Continues

As the end of 2015 nears, CMS has used its blog to reflect on its continued efforts to move the U.S. health care system from one that pays for the volume of care provided to one that pays for the value of that care.
The blog notes the replacement of the sustainable growth rate (SGR formula) with a new payment system that better supports patient-centered care; the creation of the Home Health Value-Based Purchasing model; and the introduction of Medicare reimbursement for advance care planning.
The blog also describes the many programs launched by the Affordable Care Act-created Center for Medicare and Medicaid Innovation, including the Pioneer ACO Model, the Medicare Shared Savings Program, the Comprehensive Care for Joint Replacement program, the Comprehensive Primary Care Initiative, the Independence at Home demonstration, the Bundled Payment for Care Improvement Initiative, and the State Innovation Models initiative.
Together, CMS hopes these and other programs will help achieve its stated goal of paying for 30 percent of Medicare services through alternative payment models and making 85 percent of payments based on quality or value by the end of 2016.
For a better sense of how CMS sees these efforts pushing toward its policy objectives, see the commentary “Continuing the shift from volume to results in American healthcare” here, on the CMS blog.

PA Safety Net Admin2015-11-30T06:00:46+00:00November 30th, 2015|Affordable Care Act, Health care reform, Medicare|Comments Off

OIG Reveals 2016 Plans

The U.S. Department of Health and Human Services’ Office of the Inspector General (OIG) has published its work plan for the 2016 fiscal year.
In 2016, the OIG will continue to examine all aspects of HHS endeavor, including Medicare, Medicaid, hospital services, public health activities, and more. In the coming year it will continue a number of hospital-focused projects while also focusing more on health care delivery, health care reform, alternative payment methodologies, and value-based purchasing initiatives.
Among the OIG’s planned Medicare projects in 2016 – some of them continued from the past and some of them new, quoted directly from the work plan – are:

Hospitals’ use of outpatient and inpatient stays under Medicare’s two-midnight rule. We will determine how hospitals’ use of outpatient and inpatient stays changed under Medicare’s two-midnight rule, as well as how Medicare and beneficiary payments for these stays changed, by comparing claims for hospital stays in the year prior to the effective date of the two-midnight rule to stays in the year following the effective date of that rule. We will also determine the extent to which the use of outpatient and inpatient stays varied among hospitals.
Analysis of salaries included in hospital cost reports. We will review data from Medicare cost reports and hospitals to identify salary amounts included in operating costs reported to and reimbursed by Medicare. Employee compensation may be included in allowable provider costs only to the extent that it represents reasonable remuneration for managerial, administrative, professional, and other services related to the operation of the facility and furnished in connection with patient care.
Medicare oversight of provider-based status. We will determine the number of provider-based facilities that hospitals own and the extent to which CMS has methods to oversee provider-based billing. We will also determine the extent to which provider-based facilities meet requirements described in 42 CFR Sec. 413.65 and CMS Transmittal A-03-030, and whether there were any challenges associated with the provider-based attestation review process. Provider-based status allows facilities owned and operated by hospitals to bill as hospital outpatient departments. Provider-based status can result in higher Medicare payments for services furnished at provider-based facilities and may increase beneficiaries’ coinsurance liabilities. The Medicare Payment Advisory Commission (MedPAC) has expressed concerns about the financial incentives presented by provider-based status and stated that Medicare should seek to pay similar amounts for similar services.
Comparison of provider-based and freestanding clinics. We will review and compare Medicare payments for physician office visits in provider-based clinics and freestanding clinics to determine the difference in payments made to the clinics for similar procedures and assess the potential impact on Medicare of hospitals’ claiming provider-based status for such facilities. Provider-based facilities often receive higher payments for some services than do freestanding clinics.
Review of hospital wage data used to calculate Medicare payments. We will review hospital controls over the reporting of wage data used to calculate wage indexes for Medicare payments. Prior OIG wage index work identified hundreds of millions of dollars in incorrectly reported wage data and resulted in policy changes by CMS with regard to how hospitals reported deferred compensation costs.
Inpatient rehabilitation facilities—adverse events in postacute care for Medicare beneficiaries. We will estimate the national incidence of adverse and temporary harm events for Medicare beneficiaries receiving postacute care in inpatient rehabilitation facilities (IRFs). We will also identify factors contributing to these events, determine the extent to which the events were preventable, and estimate the associated costs to Medicare.
CMS validation of hospital-submitted quality reporting data. We will determine the extent to which CMS validated hospital inpatient quality reporting data.
Ambulatory surgical centers—payment system. We will review the appropriateness of Medicare’s methodology for setting ambulatory surgical center (ASC) payment rates under the revised payment system. We will also determine whether a payment disparity exists between the ASC and hospital outpatient department payment rates for similar surgical procedures provided in both settings.
Use of electronic health records to support care coordination through ACOs. We will review the extent to which providers participating in ACOs in the Medicare Shared Savings Program use electronic health records (EHRs) to exchange health information to achieve their care coordination goals. We will also assess providers’ use of EHRs to identify best practices and possible challenges to the exchange and use of health data, such as degree of interoperability, financial barriers, or information blocking.
Accountable Care Organizations: Strategies and Promising Practices. We will review ACOs that participate in the Medicare Shared Savings Program (established by section 3022 of the Affordable Care Act). We will describe their performance on the quality measures and cost savings over the first three years of the program and describe the characteristics of those ACOs that performed well on measures and achieved savings. In addition, we will identify ACOs’ strategies for and challenges to achieving quality and cost savings.

Among the Medicaid projects the OIG will undertake, again presented in language taken directly from its work plan, are:

Transportation services—compliance with Federal and State requirements. We will determine the appropriateness of Medicaid payments by States to providers for transportation services.
Health-care-acquired conditions—prohibition on Federal reimbursements. We will determine whether selected States made Medicaid payments for hospital care associated with health-care-acquired conditions and provider-preventable conditions and quantify the amount of Medicaid payments for such conditions.
State use of provider taxes to generate Federal funding. We will review State health-care-related taxes imposed on various Medicaid providers to determine whether the taxes comply with applicable Federal requirements. Our work will focus on the mechanism States use to raise revenue through provider taxes and determine the amount of Federal funding generated.
State compliance with Federal Certified Public Expenditures regulations. We will determine whether States are complying with Federal regulations for claiming Certified Public Expenditures (CPEs), which are normally generated by local governments as part of their contribution to the coverage of Medicaid services.
Reviews of State Medicaid Fraud Control Units. We will continue to conduct in-depth onsite reviews of the management, operations, and performance of a sample of MFCUs. We will identify effective practices and areas for improvement in MFCU management and operations.
Medicaid managed care reimbursement. We will review States’ managed care plan reimbursements to determine whether MCOs are appropriately and correctly reimbursed for services provided.
Medicaid managed care entities’ identification of fraud and abuse. We will determine whether Medicaid MCOs identified and addressed incidents of potential fraud and abuse. We will also describe how States oversee MCOs’ efforts to identify and address fraud and abuse.
HRSA—duplicate discounts for 340B-purchased drugs. We will assess the risk of duplicate discounts for 340B-purchased drugs paid through Medicaid MCOs and describe States’ efforts to prevent them.

To learn more about the OIG’s plans in 2016, go here to see the document Work Plan Fiscal Year 2016.

PA Safety Net Admin2015-11-19T06:00:09+00:00November 19th, 2015|Affordable Care Act, Health care reform|Comments Off

Low-Income Workers Rejecting Health Insurance

Low-wage workers offered health insurance by their employers are largely rejecting that option, according to a report in the New York Times.
According to the Times, most of the progress in reducing the number of unemployed Americans has been made through Medicaid expansion and subsidies offered through the federal and state health exchanges. As small businesses begin to be required to offer their workers unsubsidized insurance, however, they are finding that most of their lower-wage employees are rejecting the offer. As a result, 7.5 million people last year paid the Affordable Care Act fine for failing to obtain health insurance.
A review of the profile of those who choose not to purchase employer-sponsored health insurance found that workers who earn between $15,000 and $20,000 a year purchase insurance only 37 percent of the time and that only when income rises to $45,000 does the health insurance purchase rate increase significantly.
For more information about who is and is not buying employer-sponsored health insurance and why, see this New York Times article.

PA Safety Net Admin2015-10-22T06:00:38+00:00October 22nd, 2015|Affordable Care Act|Comments Off

Increases in Medicaid Enrollment Should Slow

Growth in Medicaid enrollment, significant this year and last, should slacken in 2016, according a new Kaiser Family Foundation report.
That growth – 8.3 percent in 2014 and 13.8 percent in 2015 – should fall to approximately four percent next year. The upswing is the result of Medicaid expansion authorized by the Affordable Care Act and most of the growth was in states that expanded their Medicaid programs, although in 2015 every state experienced an increase in Medicaid enrollment.
Growth in Medicaid spending, too, is expected to decline, from 14.3 percent in 2014 and 13.9 percent in 2015 to a projected 6.9 percent in 2016.
To learn more about how, where, and why Medicaid enrollment and spending continue to grow, see this CQ HealthBeat report presented by the Commonwealth Fund.

PA Safety Net Admin2015-10-22T06:00:01+00:00October 22nd, 2015|Affordable Care Act|Comments Off

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