All posts by Jason White

Protect your bones

Brittle bones could shatter your life. Every year, more Americans are diagnosed with osteoporosis—a disease that causes bones to weaken and become more likely to break. You may not know that you have this “silent” disease until your bones are so weak that a sudden strain, bump, or fall causes your wrist to break or your hip to fracture.

Medicare can help you prevent or detect osteoporosis at an early stage, when treatment works best. Talk to your doctor about getting a bone mass measurement—if you’re at risk, Medicare covers this test once every 24 months (more often if medically necessary) when your doctor or other qualified provider orders it.

May is National Osteoporosis Awareness and Prevention Month. Learn more about what puts you at risk for osteoporosis and how to prevent and treat it at the National Osteoporosis Foundation. Watch our short video to learn more about how Medicare can help you protect your bones.

Older Americans Month 2016: Blaze a Trail

Did you know that by the year 2029, more than 20% of people in the U.S. will be at retirement age? Older adults are a vital part of our society. Since 1963, communities across the country have shown their gratitude by celebrating Older Americans Month each May. This year, to celebrate the Older Americans Act, we’re raising awareness about important issues facing older adults and highlighting how older Americans are advocating for themselves, their peers, and their communities.

Medicare helps older adults “Blaze a Trail” by helping them stay healthy and offering vital preventive services like mammograms, diabetes screenings, and colorectal cancer screenings. If you’ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention help plan to prevent disease and disability based on your current health and risk factors.

No matter what your age is, you can stay healthy, get involved, and be a trailblazer for older Americans.

Hospital Discharge: It’s One Of The Most Dangerous Periods For Patients

Within two weeks of Joyce Oyler’s discharge from the hospital, sores developed in her mouth and throat, and blood began seeping from her nose and bowels.

Her daughter traced the source to the medicine bottles in Oyler’s home in St. Joseph, Missouri. One drug that keeps heart patients like Oyler from retaining fluids was missing. In its place was a toxic drug with a similar name but different purpose, primarily to treat cancer and severe arthritis. The label said to take it daily.

“I gathered all her medicine, and as soon as I saw that bottle, I knew she couldn’t come back from this,” said the daughter, Kristin Sigg, an oncology nurse. “There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways.”

Oyler’s death occurred at one of the most dangerous junctures in medical care: when patients leave the hospital. Bad coordination often plagues patients’ transitions to the care of home health agencies, as well as to nursing homes and other professionals charged with helping them recuperate, studies show.

“Poor transitional care is a huge, huge issue for everybody, but especially for older people with complex needs,” said Alicia Arbaje, an assistant professor at the Johns Hopkins School of Medicine in Baltimore. “The most risky transition is from hospital to home with the additional need for home care services, and that’s the one we know the least about.”

TRAVIS YOUNG / AUSTIN WALSH STUDIO /2016

Kristin Sigg’s mother, Joyce Oyler, died after receiving the wrong medication after leaving the hospital. “There were many layers and mistakes made after she left the hospital. It should have been caught about five different ways,” she said. (Travis Young/Austin Walsh Studio for KHN)

Medication mistakes like the one in Oyler’s case — which, according to court records, slipped past both her pharmacist and home health nurses — are in fact one of the most common complications for discharged patients. The federal government views them as “a major patient safety and public health issue,” and a Kaiser Health News analysis of inspection records shows such errors are frequently missed by home health agencies.

Between January 2010 and July 2015, the analysis found, inspectors identified 3,016 home health agencies — nearly a quarter of all those examined by Medicare — that had inadequately reviewed or tracked medications for new patients. In some cases, nurses failed to realize that patients were taking potentially dangerous combinations of drugs, risking abnormal heart rhythms, bleeding, kidney damage and seizures.

The variety of providers that patients may use after a hospitalization — including pharmacies, urgent care clinics and a range of specialists — creates fertile ground for error, said Don Goldmann, chief medical and scientific officer at the nonprofit Institute for Healthcare Improvement. “This episodic care at different places at different times is not designed to keep the overall safety of the patient in mind,” Goldmann said.

One factor is the lack of organization and communication among these other parts of the medical system. Of the $30 billion that Congress appropriated to help shift the system to electronic medical records — to ensure better coordination of care and reduce errors across the board — none went to nursing homes, rehabilitation facilities or providers working with individuals in their homes.

Sigg says many people don’t know that lapses in communication sharing among doctors can lead to danger for patients. (Travis Young/Austing Walsh Studio for KHN)

“In retrospect, that might have been a mistake,” said Robert Wachter, a professor at the University of California, San Francisco who studies patient safety. “The systems are not adequately connected.”

At any point, problems can occur:

— At hospitals, where federal data show that fewer than half of patients say they confidently understood the instructions of how to care for themselves after discharge.

— In nursing homes, where case management frequently comes up short. A 2013 government report found more than a third of facilities did not properly assess patients’ needs, devise a plan for their care and then follow it through.

— At pharmacies, where counseling and reviewing drugs with patients is often pro forma, and better exertions do not always help. A 2012 study in the journal Annals of Internal Medicine found that half of patients had a clinically significant medication error within a month of discharge from two highly regarded academic medical centers. The study found that these errors persisted even when pharmacists took a more active role in counseling the patient and reviewing the prescription.

— And at home health agencies, where failures to create and execute a care plan are the most common issues government inspectors identify, followed by deficient medication review, according to KHN’s analysis. Over the first half of this decade, 1,591 agencies — one in eight — had a defect inspectors considered so substantial that it warranted the agencies’ removal from the Medicare program unless the lapses were remedied.

‘Devastating’ Cancer Drug

Oyler’s death in October 2013 shows how a fatal mistake can slip by multiple checkpoints. The 66-year-old retired safety manager left Heartland Regional Medical Center in St. Joseph after being treated for congestive heart failure, in which the heart fails to pump effectively, causing fluid build-up in the lungs, shortness of breath and swelling in the feet. She returned home as a hospital nurse telephoned the local Hy-Vee Pharmacy with eight new prescriptions. One was for the diuretic metolazone.

But the medications a pharmacy technician wrote down did not include metolazone. Instead it listed methotrexate, which can damage blood cell counts, organs and the lining of the mouth, stomach and intestines. The drug is so potent that the Institute for Safe Medication Practices includes it among eight “high-alert” medications with consequences so “devastating” that they warrant special safeguards against incorrect dispensing.

Oyler’s prescription included daily dosage instructions for the diuretic. Methotrexate is never supposed to be taken more than once or twice a week for patients not being treated for cancer, and almost always at a much lower dose.

JordanPrescript_770

Joyce Oyler’s prescription was written for a toxic drug instead of a common diuretic.

“Here’s a drug that every patient, even if it’s on the refill, should get counseled on, why they’re taking methotrexate and how they’re taking it because of the mistakes of errors we’ve seen with the daily dosing rather than the weekly dosing,” said Allen Vaida, a pharmacist and executive vice president at the Institute for Safe Medication Practices.

In a court deposition taken as part of the lawsuit the family brought, Hy-Vee’s pharmacist blamed himself for not catching the error. “For whatever reason, on that certain day, that didn’t trigger with me,” he said. Hy-Vee argued that its safeguards were as strong as at other pharmacies, although the pharmacy manager admitted in a deposition that “quite honestly, there was a breakdown in the system.”

The family’s attorney, Leland Dempsey, said court evidence suggested the drug mix-up was made by the pharmacy technician who transcribed the prescription orders. “The pharmacy tech made numerous spelling errors on the drugs,” he said. “She had a dosage off on another drug.”

In February, a jury awarded Oyler’s family $2 million in damages from the pharmacy. The judge lowered the award to $125,000 because of Missouri’s cap for non-economic damages in medical malpractice cases. Hy-Vee declined to comment.

Nurses Overlook Prescription Mistake

Yet the error could have been caught right away as Oyler began getting care from Heartland’s home health care agency. Medicare requires home health agencies to examine details of a patient’s medications to ensure all the drugs match the prescriptions ordered, are being taken in the right dose and frequency, and don’t have negative interactions.

Less than a year before, Missouri state inspectors had cited the agency for inadequately reviewing medications for three patients, and the agency had pledged to make improvements, records show. Still, neither of two agency nurses who visited Oyler at home stopped her from taking the wrong drug.

“Why they didn’t catch it was beyond me,” her husband, Carl, said recently. “They had a printout from the hospital,” with every medication correctly listed. “It was all there,” he said.

Kristin Sigg looks at wedding photos that include her mother. (Travis Young/Austin Walsh Studio for KHN)

Kristin Sigg looks at wedding photos that include her mother. (Travis Young/Austin Walsh Studio for KHN)

After 18 days, her family took her to North Kansas City Hospital, where doctors determined that the methotrexate had irreparably damaged her bone marrow’s ability to create blood cells. She died three days later of multiple organ failure.

“By the time we got her into the emergency room, essentially she had no blood cell count,” her husband recounted. “It was irreversible. It was a gruesome, slow, painful way to die.”

Heartland Regional Medical Center paid Oyler’s family $225,000 in a settlement, court records show. Mosaic Life Care, the name by which Heartland now operates, said in a statement that it is “consistently improving processes and adopting new technologies to further reduce risks of errors and to improve communication.”

Nonetheless, last November inspectors again cited Heartland for failing to properly review medications for two patients.

“Most people don’t know this is a problem,” Sigg said. “They assume doctors are talking to each other, until they experience it, and it’s not the case.”

If you’d like to share your reaction to this article and your experience with a home health agency, you can contact Kaiser Health News. Send an email to patients@kff.org.

Categories: Aging, Health Industry, Medicare, Syndicate

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Math Error At Rural Hospital Could Cost All Mass. Hospitals $160M In Medicare Funding


STAT:
Senate Republicans Urge Obama To Withdraw Medicare Part B Experiment


One month after the Obama administration unveiled an experiment to revamp the Medicare Part B program, more than a dozen Republican Senators are urging that it be withdrawn. At the same time, House Republicans and Democrats are circulating letters among themselves that express varying degrees of concern with the program. … Under the Part B program, doctors, and hospitals buy a medicine, and the government reimburses the average sales price plus 6 percent. But the experiment, which would run five years starting this fall, would pay physicians the average price, plus another 2.5 percent and a flat fee of $16.80, not including reductions required by sequestration, or automatic spending cuts. (Silverman, 4/29)

Medicare Pays Bonuses To 231 Hospitals With Lower Quality Because Of Cheaper Costs

The federal government paid bonuses to 231 hospitals with subpar quality because their patients tend to be less expensive for Medicare, new research shows.

The bonuses are small, generally a fraction of a percent of their Medicare payments. Nonetheless, rewarding hospitals of mediocre quality was hardly the stated goal when the Affordable Care Act created financial incentives to encourage better medical care from hospitals, doctors and other health care providers.

A study published Monday in the journal Health Affairs looked at the more than $1 billion in payments made last year in the Hospital Value-Based Purchasing program, which raises or lowers Medicare payments to hospitals based on the government’s assessment of their quality. Medicare primarily uses death and infection rates and patient surveys to judge hospitals, but it also evaluates how much each hospitals’ patients cost, both in treatment and recovery.

The 231 hospitals the study identified had below average scores on quality measures but were awarded the bonuses because caring for their patients during their stays and in the 30 days following their discharge cost Medicare less than what it cost at half of hospitals evaluated in the program.

The Centers for Medicare Medicaid Services, or CMS, began measuring cost in October 2014 to encourage hospitals to provide care in the most efficient way possible. In the period examined in the study — the federal fiscal year that ended in September 2015 — spending counted for 20 percent of a hospital’s score in determining whether a hospital would get a bonus, penalty or regular payment.

Under this formula, hospitals with Medicare spending below the median hospital were able to qualify for bonuses even though their quality measures were below the median, the study found. Patients at those 231 hospitals cost Medicare on average nearly $16,000, about $2,300 less than the average spending for the patients at other hospitals that received bonuses, according to the study’s lead author, Anup Das, a medical and health policy student at the University of Michigan.

money lean hospitalThe average bonus for those lower quality hospitals was an 0.18 percent increase in Medicare payments for each patient stay during that fiscal year. Most of the 1,700 hospitals that received a bonus that year had higher than average quality ratings, and their patients in some cases were more costly to Medicare.

“High-quality low-spending hospitals received the greatest financial benefit from the program,” the study said. “In this respect, CMS achieved its goal with the new spending measure. However, some low-quality hospitals received bonuses because of their low spending.”

In a statement, CMS said it would consider revising the program for future years so that hospitals scoring below the national median for quality would not receive a bonus. The statement also noted that this year, three-fourths of hospitals’ scores were based on quality measures. “We believe that there needs to be a balanced consideration between quality and cost, which is reflected in our scoring methodology,” the statement said.

The study found the lower-quality hospitals that received bonuses in the last fiscal year had higher death rates for heart attacks, heart failure and pneumonia than half of the nation’s other hospitals evaluated in the program. These hospitals were also less likely to follow recommended procedures for care, like choosing the right antibiotic for patients or performing an angioplasty on a heart attack patient within 90 minutes of their arrival at the hospital.

The 231 lower-quality hospitals with bonuses also received less enthusiastic ratings from patients about how well doctors and nurses communicated, responded to issues and managed pain, the study found. The study did not name the 231 hospitals.

“It’s a small decrease in quality, but the differences are significant,” Das said in an interview.

Other new federal quality payment programs created by the health law, such as accountable care organizations, deny bonuses to doctors or hospitals with substandard quality of care, no matter how efficiently they operate. The study suggested the government add a similar limitation to the Value-Based Purchasing program.

The study did not look at the current federal fiscal year, which runs through this September. This year, Medicare gave bonuses to 1,705 hospitals, averaging 0.51 percent, and reduced payments to 1,375 hospitals by an average of 0.34 percent, according to a Kaiser Health News analysis. Along with spending, Medicare’s other criteria are: death and infection rates; how faithfully a hospital followed basic clinical guidelines; and how patients rated their experiences in surveys.

Spending counts for a fourth of each hospitals’ scores, more than last year, and is scheduled to continue to do so for the next two years. The study’s lead author, Das, said in the interview that a preliminary analysis found some lower-quality hospitals again received bonuses.

Categories: Cost and Quality, Medicare, Syndicate

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231 Hospitals With Subpar Quality Awarded Bonuses From Medicare


Kaiser Health News:
Medicare Pays Bonuses To 231 Hospitals With Lower Quality Because Of Cheaper Costs


The federal government paid bonuses to 231 hospitals with subpar quality because their patients tend to be less expensive for Medicare, new research shows. The bonuses are small, generally a fraction of a percent of their Medicare payments. Nonetheless, rewarding hospitals of mediocre quality was hardly the stated goal when the Affordable Care Act created financial incentives to encourage better medical care from hospitals, doctors and other health care providers. (Rau, 5/2)

Wyden Introduces Bill Aimed At Protecting Seniors From High Drug Costs


The Hill:
Wyden Introduces Bill To Cap Drug Costs Under Medicare


Sen. Ron Wyden (Ore.), the top Democrat on the Senate Finance Committee, on Wednesday introduced a bill aimed at protecting seniors from high drug costs, an issue that has attracted growing scrutiny. Wyden’s measure would cap drug cost-sharing for Medicare enrollees so that seniors would not have to pay out of pocket costs above a roughly $7,500 cap.
In 2013, 2.9 million people in Medicare’s prescription drug program had to pay costs above that cap, Wyden’s office said. (Sullivan, 4/27)

CMS Unveils Proposed Medicare Rule To Reward Or Penalize Physicians Based On Quality Of Care


The Hill:
Obama Administration Takes Step To Reform Medicare Payments


The rule announced Wednesday gives doctors a choice of two paths, both of which seek to pay them in part based on how well they treat patients. The first path, called the Merit-Based Incentive Payment System (MIPS), would increase or decrease payments up to 4 percent in the first year based on how well doctors meet benchmarks on quality, use of electronic health records, and cost. The second path, known as advanced alternative payment models, would go even further in shifting towards rewarding quality. (Sullivan, 4/27)

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


JAMA:
Trustees Of Nonprofit Health Care Organizations: Whom Do They Serve?


Should trustees, including those serving on boards of nonprofit hospitals, physician organizations, and nonprofit health care organizations, consider every opportunity to transition from fee-for-service reimbursement to population health management and accept financial risk related to possible decreases in the volume of care patients seek at their institutions? For the purposes of this Viewpoint, population health management is a set of activities focused on a defined population that improves quality and outcomes while lowering the total costs of care and is substantially incentivized through contracts that accept financial risk and gain. From 2013 to 2014, health care expenditures increased 5.3%, substantially above the rate of inflation, and equaled 17.5% of all goods and services produced in the United States.1 Fee-for-service reimbursement results in cost increases by encouraging patient use of medical services. The majority of trustees appreciate that the revenue from fee-for-service is essential to keeping their institution financially sustainable. (Michael Jellinek, 4/26)

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 Medicare. 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.

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 2017, 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: The law does not change payments by beneficiaries. 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. If Medicare’s Part B costs increase because of the new payment formula, beneficiaries’ premiums and co-payments could potentially rise as well.

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.

This article was updated with additional information about potential costs for beneficiaries.

Categories: Cost and Quality, Medicare, Syndicate

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