CMS releases 2020 Medicare Advantage risk adjustment payment model: CMS pays Medicare Advantage plans based on a number of factors, including an individual’s severity of illness. These calculations are often made one by one, or sometimes paired (as with diabetes and heart failure). Starting in 2020, CMS will phase in a new risk-adjusted payment method that counts the number of these conditions in the calculation. It is an attempt to make payments more accurate and comprehensive.
CMS finalizes ACO overhaul, shortening pathway for financial risk: Accountable Care Organizations are most often paid on a fee for service basis, with limited downside liability for over-utilization, lower quality or patient complaints about care. ACOs were supposed to transition to a more risk-based arrangement, but few have done so. CMS is now forcing their hand by shortening the time they have to convert to the higher risk scheme.
Administrative, network costs doomed New York City health plan startups: This finding is no surprise and highlights that nothing is new in healthcare systems. This article opines about why 2 of the 3 recent NY City health plan startups failed: high administrative costs as membership grew and “rental” of a provider network. I believe that the reason Oscar is left standing is because it was better capitalized, allowing it to sustain early costs- not because they are better administered or had a better delivery model. But you decide.
Health law’s fines are not the big stick everybody thought: As previously reported, we won’t know for a while exactly how many people signed up for the insurances exchanges. However, this article points out that the penalty for not having insurance was not a significant sign-up inducement. In other words, now that the penalty is gone, people did not drop coverage. This finding flies in the face of the logic of Judge O’Conner in deciding that the fine (tax) was an essential element of the ACA.
Judge: Most Claims Can Proceed in Remicade Antitrust Claims:Continuing this week’s bad news for J&J (see yesterday’s blog), a judge has ruled that antitrust claims can proceed against the company for blocking biogeneric competition with its Remicaid product.
Exclusive: Big Pharma returning to U.S. price hikes in January after pause: After bowing to governmental pressure (at all levels) to hold down costs for their products, nearly 30 pharma companies have announce price increases for next year. This information comes from mandatory filings in California before such increases can occur. It will be interesting to see how the Trump administration deals with this change of heart.
Outgoing GOP chairman urges colleagues to oppose Trump drug pricing proposal:Speaking of federal initiatives to lower drug costs, seems like the tactics are not embraced by all- even in the same party. Outgoing Senate Finance Committee Chairman Orrin Hatch ( R-Utah) wrote a letter to his Republican colleagues urging them to oppose the President’s proposal to index American pharmaceutical prices to an international market basket.
Mixed Messages to Consumers From Medicare: Hospital Compare Grades Versus Value-Based Payment Penalty: Medicare has two ways to recognize hospital quality (or lack of it). One is the grade it gives hospitals on the hospital compare website. The other is the bonus or penalty based on the quality of care. However, this research study shows that the two are not congruous. For example: “Of 120 (4.1%) hospitals graded as ‘better’ than the national rate for HF [heart failure], none were scored as having excessive HF readmissions and 50% were penalized.” The inconsistencies are confusing for hospitals but also for the public as these penalties are often the subject of news reports. We need consistent and easily understood quality measures to aid in care seeking decisions- how will the government correct this problem?
Doctors with bad records can often still practice on patients. Here’s what needs to happen to fix this:In 1986, Congress created the National Practitioner Data Bank which is a centralized, national repository of all information about physician disciplinary actions. Before issuing a medical license, granting hospital privileges or hiring a practitioner, the decision maker is supposed to consult the Data Bank. But this procedure is not always followed. This article provides a great explanation of this issue, starting with three fundamental problems: “The system can be gamed, so not all problem doctors appear on the list; state medical boards don’t always check the data bank; and the information is off limits to those who are most at risk: patients” Sometimes having laws and organizations in place are not enough- the work actually must be done.
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New Organization Says It Is Improving Presentation of Clinical Guidelines: On July 16 of this year, AHRQ’s National Guideline Clearinghouse (NGC) was closed due to lack of funding. Shortly thereafter, ECRI Institute said it would take over the NGC’s function (originally for a fee but then changed its mind and is now free). Now, a non-profit organization, The Alliance for the Implementation of Clinical Practice Guidelines (AiCPG) is offering free guideline searches, including those archived from the NGC.
Read the announcement
Lives lost, Organs wasted: The allocation of organs for transplant is a process that still needs much reform. Logistical problems as well as geographic inequities are two major problems. This article provides some personal experiences as well as a factual presentation of this important issue.