Tag Archives: medicare news

Instead of soft-pedaling public option with Medicare buy-in, Clinton should step on the gas

Healthcare reform finally moved from the backburner to front and center recently when Democratic frontrunner Hillary ClintonHillary Rodham ClintonDNC to offer Sanders more seats on platform committee: report Booker: ‘Let Bernie make his own decisions’ Clinton to Trump: Your definition of ‘qualifications’ needs work MORE gingerly called for a public option during a Virginia campaign stop.

The truth is a major crisis has been brewing among private insurers, always the linchpin in the Affordable Care Act (ACA), and recent financial struggles prove a robust discussion on healthcare must be central to the 2016 presidential debate.

Clinton needs go even further: Her “option” only allows Americans 55-64 to buy into Medicare, but all ages need a viable public choice and should be able to buy into Medicaid or Medicare.

Two stunning announcements prove why.

Blue Cross Blue Shield’s parent company HCSC announced a $1.5 billion loss on insurance exchanges in 2015, pulling wide network offerings in their two biggest markets, Texas and Illinois, raising rates everywhere. United Health Care announced it will exit most state exchanges by 2017. Both companies attributed large losses to the unpredictable costs of insuring the previously uninsured.

These startling private sector retrenchments should concern anyone who thinks the insurance industry can provide the entire solution. One study found 2.9 million Americans will be left with only one or two choices on their state exchanges when United Health Care exits. Blue Cross Blue Shield pulled out of New Mexico’s exchange altogether because the state wouldn’t approve rate increases. Yet, there remains a strong role for private insurers, as employer-sponsored health plans netted HCSC $932 million in 2015.  

One wrinkle in this complicated story deserves note: Congressional Republicans scuttled plans to incentivize private firms in taking on the unknown, and largely unknowable, risk of covering 46 million uninsured Americans now that it’s no longer legal to deny coverage based on pre-existing conditions, a move 82 percent of Americans supported. 

Experience with other public insurance products has shown us things we didn’t know before: States that expanded Medicaid have already demonstrated better outcomes than states that haven’t, including higher rates of coverage and increased access to prescription medications for low-income families. These states saved money through reduced spending and uncompensated care for the uninsured, and gained tax revenue collected from providers. Medicaid expansion also reduced financial strain on previously uninsured Americans who struggled to pay medical bills.

To be sure, more than 30 million Americans still don’t have health insurance, and an insurance card is not the same thing as health care access. Increasing coverage is a critical first step. Among the insured,  rates of medical debt have decreased, as have rates of delaying care, according to The Commonwealth Fund. The industry as a whole is moving toward patient centered, value-based  care that lowers costs by keeping people healthy.

As a public health professional who always supported a comprehensive public option, I vividly remember a friend working behind the scenes in 2009, telling me a public option wasn’t politically viable. He tried to console me with historical parallels, in the way only policy wonks can: “When FDR passed Social Security, it only covered white men. This is the first draft. We have to get something passed and then we can tweak it later.”

The time for tweaking has come.

The government has to do more than incentivize insurers. Meanwhile, another wrinkle deserves note. GOP frontrunner Donald TrumpDonald TrumpWarren: Trump ‘trolls for votes’ from working class Trump: ‘Who the hell cares if there’s a trade war?’ Trump mocks Christie’s weight at fundraiser: ‘No more Oreos’ MORE’s health care platform wants to abolish Obamacare in favor of free market principles, but his goals are the same as ACA: “Broaden healthcare access, make healthcare more affordable and improve the quality of the care available to all Americans.” 

If Clinton embraced a comprehensive public option as recent polling suggests Americans are more open to it just might prove a comparative advantage.


Stephanie E. Farquhar, Ph.D., is a Dallas Public Voices participant and public health executive.

Medicare freeze plan will only cause pain

I WOULD like to make comment on the the article that revealed the AMA was concerned healthcare costs would go up under rebate freeze published earlier this month.

The Australian Diabetes Educators Association (ADEA) is concerned about the impact on people with diabetes from the Medicare Freeze extended until 2020 and the cut in aged care funding by $1.2b over four years.

The Medicare freeze means that people with diabetes who need to see a Credentialled Diabetes Educator (CDE), are less likely to be able to afford to see them.

This exacerbates the current Medicare restrictions of five visits a year for people with a chronic condition to an allied health processional, including a CDE.

It is hit or miss if they ever get to see a CDE unless they pay full fee for the visit.

This is made worse by the fact that CDE services provided by a nurse as distinct from an allied health CDE, are unlikely to be rebated through private health insurance. Around 85% of CDEs are nurses.

Tracy Aylen, ADEA President, said “CDEs are the gold standard of diabetes education; they are the health professionals with the skills and training to support behavioural change in people with diabetes to prevent diabetes, reverse diabetes to non-diabetes levels and prevent deterioration of complications”.

We have a new National Diabetes Strategy that aims to improve outcomes for people with diabetes that does not yet have a clear implementation plan and we have funding reductions that will impact adversely on people with diabetes.

ADEA calls on the government to identify how people with diabetes will receive the quality care they should be able to receive.

Diabetes prevalence increases rapidly with age up to age 75, with rates among 65-74 year-olds (16%) 3 times as high as for 45-54 year-olds (5%) and almost double the rate for 55-64 year olds (9%).

VY LE Diabetes Educators

Labor’s Medicare pledge wins over doctors

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Labor has promised to lift a controversial freeze on government payments to doctors, if elected.

Labor candidate for Corangamite Libby Coker visits Dr Cameron Profitt at his Bannockburn Surgery to discuss the impact policy will have on regional services. Picture: Peter Ristevski

Doctors have welcomed Labor’s election pledge to end the freeze on Medicare rebates that has seen 60 per cent of GPs plan to end bulk billing and introduce a fee of over $15 a visit.

After its plan for a GP copayment was defeated the Government froze Medicare rebates for GPs for four years at 2014 levels and in last weeks budget announced the freeze would extend for another two years until 2019-2020 to save over $900 million.

Doctors claimed the freeze will send bulk billing doctors broke as they face rising wages bills for nurses and receptionists and rising rents without their Medicare payments rising in line with inflation.

Labor candidate for Corangamite Libby Coker visits Dr Cameron. Labor has committed to restore indexation of Medicare, which was frozen by the Coalition in the latest budget. Picture: Peter Ristevski

Labor candidate for Corangamite Libby Coker visits Dr Cameron. Labor has committed to restore indexation of Medicare, which was frozen by the Coalition in the latest budget. Picture: Peter RistevskiSource:News Corp Australia

A survey of 500 doctors published this week found 60 per cent of GPs were planning to end bulk billing and introduce a fee of over $15 in response to the government’s freeze.

The government is facing a concerted campaign against the freeze with doctors putting up posters campaigning against it in their surgeries and posting antifreeze messages on prescriptions.

Labor has described the freeze as an attempt to introduce a Medicare copayment by stealth and announced it will end the freeze on Medicare rebates in January next year.

AMA President, Professor Brian Owler, said Labor’s pledge would remove a potentially devastating blow to medical practice in Australia, particularly general practice.

“The medical profession has been united in its strident opposition to the Government’s Medicare freeze policy, and we will campaign against it until it is withdrawn,” Professor Owler said.

“Labor’s announcement means that there is a real difference between the major parties on health policy,” he said.

“Many GPs are now at a tipping point. With the freeze stretching out for seven years, they have no choice but to pass on the increased costs of running their practices to patients.”

Opposition Health spokeswoman Catherine King says one in 20 Australians are already delaying visiting their GP, or do not visit at all, because of cost.

“This can lead to conditions deteriorating and people being admitted to hospital — meaning worse outcomes for the patient and greater cost to the health system. It is vital we don’t create barriers for anyone who needs to see their GP,” she said.

“The Liberals’ assault on Medicare and universal healthcare must stop,” she said.

A prescription form showing the protest against the Turnbull Government’s Medicare freeze. Picture: Calum Robertson

A prescription form showing the protest against the Turnbull Government’s Medicare freeze. Picture: Calum RobertsonSource:News Corp Australia

The Parliamentary Budget Office says Labor’s policy will cost $2.4 billion over the next four years.

The Royal Australian College of General Practitioners also welcomed Labor’s pledge to end the Medicare freeze.

“The RACGP has repeatedly underlined the risk to quality patient care, the potential worse health outcomes for individuals, the increased on costs to our extraordinary expensive hospital system, and the unintended but inevitable consequences to practice viability,” RACGP president Frank Jones said.

He said the college’s “You’ve Been targeted Campaign” which warns patients about how the freeze could see an end to bulk billing will be accelerated in the wake of Labor’s announcement.

“We are encouraged by news today that the Federal opposition will rescind the freeze from Jan 1 2017 — yet we await the fine detail,” Dr Jones said.

“We urge the Federal Government to act now — reverse their freeze; it’s bad economics and it’s bad for the health of all Australians,” he said.

Critics Of Medicare’s Overall Hospital Star Rating Push…

Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious.

The Centers for Medicare Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. The delay came after a majority of members of Congress signed a letter supporting the hospital industry’s concerns.

Hospital leaders who previewed the preliminary rating system say the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare’s Hospital Compare website. The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility’s rating.

Steven Lipstein, president of BJC HealthCare, a St. Louis-based nonprofit that runs 14 hospitals, said the ones in his organization that earned five stars were smaller, located in affluent areas and handled less complicated cases. “They don’t have comprehensive cancer centers, they don’t have major cardiovascular disease, they don’t have neuro-specialties,” he said.

BJC’s more advanced hospitals did worse, he said. “That’s not surprising when you look inside the ratings and see how they’re built,” he added.

Consumer advocates defend the rating system, saying that while not perfect, it correctly reflects higher rates of problems in some big institutions despite their lofty reputations. They worry that delay and congressional resistance are undermining Medicare’s attempt to help consumers select a hospital based on something more substantive.

“The star ratings hopefully will get quality into that decision-making process,” said Andrew Scholnick, a lobbyist for AARP, the advocacy group for seniors.

Medicare officials initially said they hoped to release the ratings to the public in July. But in a presentation to hospitals and other interested parties last Thursday, they did not set a firm date.

Medicare already has made minor tweaks in the formula to calculate the stars, but it remains a tough grader, the presentation shows. If Medicare releases the star ratings in July, nearly half of the 3,658 hospitals being evaluated would be getting three stars, according to Medicare’s preliminary calculations. Just 100 hospitals would receive five stars, while 135 would receive a single star.

Officials indicated they were standing firm in their intention to eventually release the scores. “The Overall Star Rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare,” the presentation said. Officials plan to update the scores every three months through the end of this year and then twice thereafter.

The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments.

Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, nearly half of major teaching hospitals are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications. Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates.

Some health care researchers are also skeptical. “If you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they’re the bomb, there’s a disconnect,” said Ashish K. Jha, a professor at Harvard’s public health school. “If it completely contradicts everything you’ve known, you need to ask yourself, ‘Did I not understand the way hospital care works, or is there a problem with the metric?’”

Medicare’s move toward using star ratings is part of a greater focus on easy-to-grasp composite judgments of hospital quality. The Leapfrog Group, a nonprofit patient safety group, uses report-card letter grades to characterize hospital safety based on many of the same individual measures as Medicare. Healthgrades, a Denver-based company, judges hospital quality with one, three or five stars. Consumer Reports calculates a safety score on a 100-point scale.

Medicare hopes a star rating from the government will carry even more credibility.

“People need this information now,” Scholnick said. “Trying to wait until everyone’s 100 percent happy with everything just delays it further than it needs to be.”

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

 

Oncologists: Medicare Proposal Will Limit Cancer Patients’ Access to Drugs, Endanger Chances of Healing

SAN DIEGO, May 17, 2016 (GLOBE NEWSWIRE via COMTEX) —

A Medicare proposal for testing new ways to pay for drugs may jeopardize cancer patients’ health and chances of recovery, may also create two unequal classes of patients, and could further result in more patients being forced to seek costlier treatment in hospitals, says one of California’s largest private oncology practices.

California Cancer Associates for Research and Excellence (cCARE) is joining the American Society of Clinical Oncology (ASCO) and Community Oncology Alliance (COA) in their call for the Centers for Medicare and Medicaid Services (CMS) to “withdraw an experiment of this magnitude without first understanding its potential impact on patient care.”

Particularly troubling, doctors say, is that under the CMS proposal, Medicare patients will be selected at random to participate in the test, which will influence which medications they receive. They will not be aware of their participation in the program, will not have the opportunity to give their informed consent and will not have the ability to opt out.

Physicians fear that the proposal will create two classes of patients: those with access to the more advanced, often more expensive treatments, and those who may be involuntarily relegated to cheaper and sometimes older, less effective drugs.

Currently, Medicare reimburses oncologists (specialists in cancer and blood diseases) for drugs given in clinics to cancer and hematology (blood disorder) patients at a rate of the average price of each drug plus an add-on fee of 6 percent. Physician groups – which typically buy and store several weeks-worth of drugs in advance of use – must individually negotiate the drug prices they pay each manufacturer in hopes of keeping their costs within their Medicare reimbursements.

In an attempt to control rising drug costs, the CMS proposal – alongside legislative cuts – calls for reducing the add-on fee paid to doctors to less than 1 percent plus paying an additional flat fee of $16.80 per day per drug per patient. The test would begin in late 2016 and run for five years.

While the percentage reduction in add-on fees may not seem significant, said William J. Jawien, M.D., cCARE medical director, it could make medicines prohibitively more expensive than what Medicare pays doctors for them. Such losses multiplied by thousands of patients receiving the medications over time at just one medical practice means “a physician may have to choose between doing what’s best for patients and unsustainable financial losses.”

As well intentioned as the cost-control proposal may be, Dr. Jawien said, “we believe this approach is unethical and rife with flawed economics. The CMS sought to cut Medicare Part B drug reimbursements in 2005 and again 2012, and it resulted in a major shift of cancer care to the more expensive hospital setting.”

Due to negotiating clout, hospitals are typically able to procure drugs in higher volumes at lower costs. But the net effect is an increase in treatment costs overall, according to the Community Oncology Alliance (COA), a patient advocacy and lobbying group based in Washington, D.C.

In 2004, the COA reports, independent community cancer clinics such as cCARE delivered 84 percent of chemotherapy in the United States. However, as a result of CMS’ Part B experiments, by 2014 that number had fallen to 54 percent, with the remaining treatments going to hospitals, where overall costs can be higher.

The net effect is that in 2014 alone, the COA says, taxpayers shelled out in excess of $2 billion more for chemotherapy than they would have had the site-of-service not shifted to hospitals.

“Our doctors support the laudable effort to drive down the costs of cancer care,” said Dr. Jawien. “However, this proposal is not well thought out. It will take decision making out of many patients’ hands and endanger their health, and will likely actually drive healthcare costs up rather than down.”

For more information, the Community Oncology Alliance (COA) recently issued a 33-page response to the CMS proposal.

 

 MEDIA CONTACT: Paul Kellogg Multimedia PR Director (303) 382-2999 PaulK@VanguardCommunications.net 

Copyright (C) 2016 GlobeNewswire, Inc. All rights reserved.

Avoidable Hospital Admissions Drop With Medicare Advantage

The research, “Understanding the Impact of Medicare Advantage on Hospitalization Rates: A 12-State Study,”(34 page PDF) used data from the dozen states that specifically identify whether a patient’s primary payer is Medicare Advantage; most states do not make this distinction, reporting only that the primary payer is Medicare. Still, said the authors, the 12 states included appear to be representative of all states in terms of race, ethnicity, poverty rates and physician workforce.

The lower rate of avoidable hospitalizations persisted after researchers controlled for age, gender, race/ethnicity, region and “various proxies for health,” they wrote.

Medicare Advantage costs are market-sensitive, and some analysts question whether CMS should be paying private insurers a higher premium to care for Medicare patients. In some states, such as Oregon, Medicare Advantage plans are much more expensive than traditional fee-for-service Medicare.

Andrew Bazemore, M.D., M.P.H., director of the Graham Center, was one of the authors of the study.

“Using a larger study area and more contemporary data and methods, this work confirms previous evidence showing that you tend to find fewer avoidable hospitalizations in areas with high penetration of Medicare Advantage and among individual beneficiaries using these plans compared to traditional Medicare,” Bazemore told AAFP News.

Graham Center researchers went a step beyond previous studies by also measuring hospitalizations that are planned in an effort to prevent worse outcomes, such as a patient receiving a new pacemaker. These “referral-sensitive” admissions increase the overall hospitalization rate, but they indicate patients are receiving better care. Medicare Advantage patients were more likely to have referral-sensitive hospitalizations.

Researchers said Medicare Advantage also could have “spillover effects” that positively affect the care of others. An example they cited suggests that an increase in the number of Medicare Advantage patients could lead to fewer MRI machines in an area, which could result in fewer MRI scans overall.

“Particularly in areas where providers are receiving some form of comprehensive payment for Medicare Advantage patients, the effect may result from enabling better primary care, as we found in a previous study of the WellMed health system in Texas,”(11 page PDF) Bazemore said. “In that study, we revealed how a primary care-driven accountable care organization used effective primary care to reduce mortality and improve outcomes in a Medicare Advantage population.”

He was quick to add that positive trends cannot be applied across the board. WellMed demonstrated early success but has struggled to replicate the model outside its principal territory.

A steady rise in the volume of Medicare Advantage combined with more capitation payments can allow physicians to make practice changes that enable more comprehensive care while they closely monitor chronic care patients.

There were some exceptions in hospital data by state. Rhode Island, Oregon and Massachusetts reported higher rates of avoidable hospitalizations for Medicare Advantage enrollees compared with traditional Medicare beneficiaries, which the researchers said suggests that Medicare Advantage attracts less healthy patients in these states. On the other hand, Medicare Advantage patients in Arizona, Maryland, Michigan and New Jersey reported substantially lower hospitalization rates compared to traditional Medicare patients.

“Medicare Advantage is merely a payment mechanism, and a heterogeneous one at that,” Bazemore said. “It may enable the primary care function in certain markets and conditions, but we can’t assume similar effects in all situations and markets.”

Related AAFP News Coverage
Panelists Call Medicare Advantage Model for Chronic Care
(3/16/15)

Hillary Clinton’s modestly radical idea for Medicare

Hillary Clinton wants Americans to have access to Medicare starting at age 50. It’s an idea well worth considering, not least because so many Americans aged 50 to 64 who don’t have job-based health insurance struggle to afford the relatively high premiums they’re charged for private plans. And Medicare is a popular, battle-tested and relatively inexpensive insurance system, costing less per person than private insurance.

Such an expansion would have to be carefully designed, however, to make sure Medicare premiums for this age group accurately and transparently reflect the cost of coverage. Underpricing would undercut private insurers competing for the same customers, and also saddle taxpayers with the extra cost.

The most straightforward approach would be to offer people younger than 65 a price equal to the full cost of their coverage. That would probably be at least $7,600 for people in their early 60s — an estimate the Congressional Budget Office came up with in 2008. Today, the figure would be even higher, and it’s not clear how many people would want to pay it.

In contrast, the average second-most-generous Obamacare plan this year costs $10,911 for a 60-year-old. But the government subsidizes those premiums through a tax credit to people whose incomes are less than 400 percent of the poverty line. It would make sense to offer the same subsidies to people who would buy into Medicare.

Boozman-sponsored bill adds radiologist assistants to Medicare list

WASHINGTON — Medicare would allow for the designation of radiologist assistants as “non-physician providers” under bipartisan legislation filed Tuesday, making it easier for doctors to use the services of these highly trained health professionals.

The Medicare Access to Radiology Care Act of 2016 is sponsored by Republican U.S. Sen. John Boozman of Arkansas and Democratic U.S. Sen. Bob Casey of Pennsylvania.

Supporters say the legislation would increase efficiency and lower the cost for patients and their insurers.

At a Capitol Hill news conference Tuesday morning, Boozman and a group of Arkansas radiologists said the legislation is needed.

“You know something’s good when everybody is in agreement on the provider side. That is a rarity,” said Boozman of Rogers.

A House version of the legislation was filed in February and is co-sponsored by 25 lawmakers, including the four members from Arkansas.

“It’ll allow radiologists to see more patients, see them in a more efficient way and, ultimately, it’s going to be a cost saver,” Boozman said.

The measure enjoys widespread support from medical professionals at the University of Arkansas for Medical Sciences and elsewhere.

Dozens of health care groups have called for the radiology assistants’ role to be recognized, including the American College of Radiology, the American Society of Radiology Technologists, Mercy Hospital in Rogers and the Central Arkansas Veterans Healthcare System.

The Centers for Medicare and Medicaid Services will only reimburse for a radiology assistant’s services if a doctor has provided “personal supervision.” In other words, the radiologist must be physically in the procedure room while the assistant completes the work.

The bill’s advocates argue that it’s sufficient for a doctor to be in the building, providing “direct supervision” and offering advice as needed. Most states do not require personal supervision.

Just over a decade ago, schools across the country, including UAMS, began offering radiology assistant programs.

The extra schooling gives radiology assistants more advanced training than radiology technologists, enabling them to complete some tasks that had previously been handled by radiologists.

Dr. Scott Harter, chief of radiology for Baptist Health, says radiology assistant programs were launched with the expectation that Medicare would treat them like other “physician extenders,” such as physicians’ assistants and nurse practitioners.

But so far, Medicare hasn’t treated them as analogous.

“Medicare looks at one of these radiology assistants as if they were still at that radiology technologist level. … Their skill level is advanced beyond that, considerably advanced,” Harter said.

The radiology assistants have an impressive “level of understanding and technical expertise and efficiency,” he said. “They’re not going to be running off willy-nilly doing things they shouldn’t. I can come to the room if need be in just a few steps, but I don’t have to be looking over their shoulder. That’s babysitting they don’t need. They’re far beyond that.”

Typically, Medicare’s billing rates for physician extenders are beneath those for physicians, potentially leading to future cost savings.

If the Medicare program continues to undervalue the services of radiology assistants, there will be consequences for the educational institutions and their graduates, Harter predicted.

“Without that recognition, these individuals are going to lose their jobs and the programs are going to fold. They’re going to shut down. Some of them already have,” he said.

Metro on 05/18/2016

Massive Medical Network Should Help Ease Medicare Transition

elderly wheelchair

Doctors and other healthcare providers across the nation have been bracing for enormous changes to the way they are paid by Medicare to treat seniors, as the federal government shifts to a system that rewards quality instead of quantity.

In the Garden State this transition could be tempered by the work of a new peer-exchange physician group that was formed to identify best practices and help build a unified system of effective quality metrics.

The New Jersey Health Care Quality Institute joined the New Jersey Innovation Institute Tuesday to announce a partnership to develop a practice transformation network over the next three and a half years. The Innovation Institute, a corporation connected with the New Jersey Institute of Technology, received a $50 million federal grant last fall when it was selected as one of 29 sites nationwide to organize such a network.

The peer-network program is one of several efforts the federal government has launched to help doctors, hospitals and other healthcare providers cope with an avalanche of changes in the way they get paid to treat patients. It results from a 2015 law that calls for an overhaul to the Medicare payment system, but also reflects the goals of the 2010 Affordable Care Act, which –among other things — was designed to keep patients healthy and reduce overall healthcare costs.

Earlier this month the Centers for Medicare and Medicaid Services proposed two payment systems that would tie Medicare reimbursements to specific quality benchmarks or positive patient outcomes, both significant departures from the current fee-for-service model that pays doctors for each treatment they provide. The regulations, open for comment until late June, are expected to be adopted this fall.

“This is not something that is going away,” said Linda Schwimmer, president and CEO of the Health Care Institute. “This is the future of how we are paying for medical care in America.”

Tomas Gregorio, senior executive director of healthcare systems innovation at NJII, said doctors are overwhelmed by the changing landscape and the patchwork of new requests from government payers, like Medicare and Medicaid, as well as private insurance companies, for data on quality patient outcomes.

“They have so many initiatives they have to be a part of,” he said. “We need to create that one-stop shop.”

The practice transformation network will directly involve 11,500 doctors, a mix of primary-care providers and specialists; these physicians must agree to share clinical data and participate in group discussions designed to tease out how providers can best meet quality metrics, Schwimmer explained. The new CMS regulations reward hospitals that reduce readmission rates and infection rates, for example, and penalize doctors when patients miss follow-up appointments or don’t take their medications.

NJII has already recruited thousands of doctors and the Health Care Quality Institute will help pull in additional participants and connect the group with other industry leaders, she added. The network also hopes to learn from Accountable Care Organizations, provider groups set up to focus on quality outcomes, and private insurance companies about the value-based metrics they are using in an effort to identify a consistent set of quality measurements for all patients, regardless of who is paying for their care.

In October, network members will also start to spread the gospel of their findings, and Schwimmer said the New Jersey Academy of Family Physicians will lead much of the on-the-ground work. Transformation coaches will be dispatched to help individual practices provide care that meets these metrics, and learning groups, conferences, and webinars will help disseminate the information to providers across New Jersey and beyond. Each of the 29 project sites is connected through various professional networks to colleagues nationwide, she noted.

Gregorio also envisions a web portal that would allow physicians to enter quality clinical data once that could then be automatically shared with all payers who require such metrics.

“We’re building that gateway to allow for that integration to happen and the reporting that these doctors are going to do for the rest of their lives,” he said.

While Patient Transformation Networks are fairly new, other efforts to bend the cost curve by rewarding quality have already had a positive impact. According to Sean Cavanaugh, who leads the Medicare program at the Centers for Medicare and Medicaid Services, these initiatives are already saving money and keeping patients healthier.

Medicare, which covers some 55 million seniors, cost the federal government almost $600 billion in 2014 and that figure will only rise as more baby boomers become eligible. But Cavanaugh told industry officials gathered for the Health Care Quality Institute’s spring conference earlier this month that, based in part on programs to improve value, the cost projection for 2020 is already $200 billion less than experts anticipated six years ago, when the ACA was approved.

Critics Of Medicare’s Overall Hospital Star Rating Push For Changes

Over the past decade, the federal government has publicized 115 different ways to measure medical quality in hospitals, from assessing wait times in emergency rooms and noise levels outside hospital rooms to tracking blood clots in surgical patients. But the latest effort, to combine dozens of metrics into one patient-friendly quality indicator, has proven the most contentious.

The Centers for Medicare Medicaid Services recently postponed its plan to release the new rating system, which would award one star to the worst-quality facilities and five stars to those with the best marks. The delay came after a majority of members of Congress signed a letter supporting the hospital industry’s concerns.

Hospital leaders who previewed the preliminary rating system say the formula seems skewed against institutions that treat the poorest or toughest patients, meaning those with complex illnesses. The number of stars would be based on 64 different measures, which are posted on Medicare’s Hospital Compare website. The metrics on mortality, readmission, patient experience and patient safety are the most influential, each representing 22 percent of a facility’s rating.

Steven Lipstein, president of BJC HealthCare, a St. Louis-based nonprofit that runs 14 hospitals, said the ones in his organization that earned five stars were smaller, located in affluent areas and handled less complicated cases. “They don’t have comprehensive cancer centers, they don’t have major cardiovascular disease, they don’t have neuro-specialties,” he said.

BJC’s more advanced hospitals did worse, he said. “That’s not surprising when you look inside the ratings and see how they’re built,” he added.

Consumer advocates defend the rating system, saying that while not perfect, it correctly reflects higher rates of problems in some big institutions despite their lofty reputations. They worry that delay and congressional resistance are undermining Medicare’s attempt to help consumers select a hospital based on something more substantive.

“The star ratings hopefully will get quality into that decision-making process,” said Andrew Scholnick, a lobbyist for AARP, the advocacy group for seniors.

Medicare officials initially said they hoped to release the ratings to the public in July. But in a presentation to hospitals and other interested parties last Thursday, they did not set a firm date.

Medicare already has made minor tweaks in the formula to calculate the stars, but it remains a tough grader, the presentation shows. If Medicare releases the star ratings in July, nearly half of the 3,658 hospitals being evaluated would be getting three stars, according to Medicare’s preliminary calculations. Just 100 hospitals would receive five stars, while 135 would receive a single star.

Officials indicated they were standing firm in their intention to eventually release the scores. “The Overall Star Rating represents a performance summary designed to facilitate patient and consumer use of Hospital Compare,” the presentation said. Officials plan to update the scores every three months through the end of this year and then twice thereafter.

The broader debate about the government judging hospitals has been going on since Medicare began publishing quality ratings in 2005. But it has intensified since passage of the Affordable Care Act, which instructed Medicare to use quality metrics in setting payments.

Teaching hospitals as a group have tended to fare poorly from some of these financial incentives. This year, for instance, nearly half of major teaching hospitals are losing 1 percent of their Medicare payments because of high rates of infections and surgical complications. Facilities with more low-income patients, who often face difficulties affording medication, following complicated recovery instructions and getting to doctors regularly, typically have higher readmission rates.

Some health care researchers are also skeptical. “If you come out with a rating that says Cleveland Clinic is terrible but podunk hospital in North Carolina, they’re the bomb, there’s a disconnect,” said Ashish K. Jha, a professor at Harvard’s public health school. “If it completely contradicts everything you’ve known, you need to ask yourself, ‘Did I not understand the way hospital care works, or is there a problem with the metric?’”

Medicare’s move toward using star ratings is part of a greater focus on easy-to-grasp composite judgments of hospital quality. The Leapfrog Group, a nonprofit patient safety group, uses report-card letter grades to characterize hospital safety based on many of the same individual measures as Medicare. Healthgrades, a Denver-based company, judges hospital quality with one, three or five stars. Consumer Reports calculates a safety score on a 100-point scale.

Medicare hopes a star rating from the government will carry even more credibility.

“People need this information now,” Scholnick said. “Trying to wait until everyone’s 100 percent happy with everything just delays it further than it needs to be.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.