Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies. Final rule.

This final rule revises the conditions of participation (CoPs) that home health agencies (HHAs) must meet in order to participate in the Medicare and Medicaid programs. The requirements focus on the care delivered to patients by HHAs, reflect an interdisciplinary view of patient care, allow HHAs greater flexibility in meeting quality care standards, and eliminate unnecessary procedural requirements. These changes are an integral part of our overall effort to achieve broad- based, measurable improvements in the quality of care furnished through the Medicare and Medicaid programs, while at the same time eliminating unnecessary procedural burdens on providers.

Glycosylated hemoglobin and hyperbaric oxygen coverage denials.

Some Medicaid and Medicare fiscal intermediaries are denying hyperbaric oxygen (HBO2) therapy for diabetic foot ulcer (DFU) patients if the glycosylated hemoglobin (HbA1c) > 7.0%. We performed multiple PubMed searches for any diabetic wound healing clinical trial that documented HbA1c and had a wound healing endpoint. We scrutinized 30 peer-reviewed clinical trials, representing more than 4,400 patients. The average HbA1c from the intervention side of the studies was 8.6% (7.2% - 9.9%) and the control/sham side was 8.3% (6.0% - 10.6%). Twelve studies made a direct attempt to link HbA1c and wound healing. Four retrospective studies and one prospective cohort study assert that lower HbA1c favors wound healing, but review of the studies reveal design flaws that invalidate these conclusions. In total, 25 studies showed no direct correlation between HbA1c levels and wound healing. There was no randomized controlled trial (RCT) data demonstrating that HbA1c < 7.0% improves diabetic wound healing. In every study reviewed, wounds healed with high HbA1c levels that would be considered poorly controlled by the American Diabetes Association (ADA). Frequently, patients lack optimal blood glucose control when they have a limb-threatening DFU. The evidence supports that denying hyperbaric oxygen to those with HbA1c > 7.0% is unfounded.

Medicare reimbursement attributable to catheter-associated urinary tract infection in the inpatient setting: a retrospective cohort analysis.

BACKGROUND: Most catheter-associated urinary tract infections (CAUTIs) are considered preventable and thus a potential target for health care quality improvement and cost savings. OBJECTIVES: We sought to estimate excess Medicare reimbursement, length of stay, and inpatient death associated with CAUTI among hospitalized beneficiaries. RESEARCH DESIGN: Using a retrospective cohort design with linked Medicare inpatient claims and National Healthcare Safety Network data from 2009, we compared Medicare reimbursement between Medicare beneficiaries with and without CAUTIs. SUBJECTS: Fee-for-service Medicare beneficiaries aged 65 years or older with continuous coverage of parts A (hospital insurance) and B (supplementary medical insurance). RESULTS: We found that beneficiaries with CAUTI had higher median Medicare reimbursement [intensive care unit (ICU): $8548, non-ICU: $1479) and length of stay (ICU: 8.1 d, non-ICU: 3.6 d) compared with those without CAUTI controlling for potential confounding factors. Odds of inpatient death were higher among beneficiaries with versus without CAUTI only among those with an ICU stay (ICU: odds ratio 1.37). CONCLUSIONS: Beneficiaries with CAUTI had increased Medicare reimbursement and length of stay compared with those without CAUTI after adjusting for potential confounders.

Developing a viable alternative to Medicare's physician payment strategy.

Since 1992 Medicare has reimbursed physicians on a fee-for-service basis that weights physician services according to the effort and expense of providing those services and converts the weights to dollars using a conversion factor. In 1997 Congress replaced an existing spending constraint with the Sustainable Growth Rate (SGR) to reduce reimbursements if overall physician spending exceeded the growth in the economy. Congress, however, has routinely overridden the SGR because of concerns that reduced payments to physicians would limit patients' access to care. Under continued pressure to override scheduled fee reductions or eliminate the SGR altogether, Congress is now considering legislation that would reimburse physicians to improve quality and lower costs-two things that the current system does not do. This article reviews several promising models, including patient-centered medical homes, accountable care organizations, and various payment bundling pilots, that could offer lessons for a larger reform of physician payment. Pilot projects that focus exclusively on alternative ways to reimburse physicians apart from payments to hospitals, such as payments for episodes of care, are also needed. Most promising, Congress is now showing bipartisan, bicameral interest in revising how Medicare reimburses physicians.

Impact of Doctors' Resistance on Success of Drug Utilization Review System / 대한의료정보학회지

OBJECTIVES: The drug utilization review (DUR) system, which checks any conflict event of medications, contributes to improve patient safety. One of the important barriers in its adoption is doctors' resistance. This study aimed to analyze the impacts of doctors' resistance on the success of the DUR system. METHODS: This study adopted an augmented the DeLone and McLean Information System (D&M IS) Success Model (2003), which used doctors' resistance as a socio-technological measure. This study framework is the same as that of the D&M IS Success Model in that it is based on qualities, such as system, information, and services. The major difference is that this study excluded the variable 'use' because it was not statistically significant for mandatory systems. A survey of doctors who used computers to enter prescriptions was conducted at a Korean tertiary hospital in February 2012. RESULTS: This study is very meaningful in that it is the first study to explore the success factors of the DUR system associated with doctors' resistance. Doctors' resistance to the DUR system was not statistically associated with user usefulness, whereas it affected user satisfaction. CONCLUSIONS: The results indicate that doctors still complain of discomfort in using the DUR system in the outpatient clinical setting, even though they admit that it contributes to patient safety. To mitigate doctors' resistance and raise user satisfaction, more opinions from doctors regarding the DUR system have to be considered and have to be reflected in the system.

Non-assigned Medicare payment increases practice revenue & lowers Medicare costs.

Private practice physicians can increase practice revenue and also save Medicare money. What seems like a paradox is instead a choice. The non-assigned Medicare payment option allows physicians to bill 8% more for their services. This also decreases Medicare payment 5%. Selecting the non-assigned payment method does not require permission from Medicare or any Medicare contractor. This is a physician decision and for 2014 must be made between mid-November and year end 2013.

Regulatory neutrality is essential to establishing a level playing field for accountable care organizations.

Accountable care organizations (ACOs) are among the most widely discussed models for encouraging movement away from fee-for-service payment arrangements. Although ACOs have the potential to slow health spending growth and improve quality of care, regulating them poses special challenges. Regulations, particularly those that affect both ACOs and Medicare Advantage plans, could inadvertently favor or disfavor certain kinds of providers or payers. Such favoritism could drive efficient organizations from the market and thus increase costs or reduce quality of and access to care. To avoid this type of outcome, we propose a general principle: Regulation of ACOs should strive to preserve a level playing field among different kinds of organizations seeking the same cost, quality, and access objectives. This is known as regulatory neutrality. We describe the implications of regulatory neutrality in four key areas: antitrust, financial solvency regulation, Medicare governance requirements, and Medicare payment models. We also discuss issues relating to short-term versus long-term perspectives--to promote the goal of regulatory neutrality and allow the most efficient organizations to prevail in the marketplace.

Two-thirds of primary care physicians accepted new Medicaid patients in 2011-12: a baseline to measure future acceptance rates.

As part of the Affordable Care Act, primary care physicians providing services to patients insured through Medicaid in some states will receive higher payments in 2013 and 2014 than in the past. Payments for some services will increase to match Medicare rates. This change may lead to wider acceptance of new Medicaid patients among primary care providers. Using data from the 2011-12 National Ambulatory Medical Care Survey Electronic Medical Records Supplement, I summarize baseline rates of acceptance of new Medicaid patients among office-based physicians by specialty and practice type. I also report state-level acceptance rates for both primary care and other physicians. About 33 percent of primary care physicians (those in general and family medicine, internal medicine, or pediatrics) did not accept new Medicaid patients in 2011-12, ranging from a low of 8.9 percent in Minnesota to a high of 54.0 percent in New Jersey. Primary care physicians in New Jersey, California, Alabama, and Missouri were less likely than the national average to accept new Medicaid patients in 2011-12. The data presented here provide a baseline for comparison of new Medicaid acceptance rates in 2013-14.

Post-acute care and ACOs - who will be accountable?

OBJECTIVE: To determine how the inclusion of post-acute evaluation and management (E&M) services as primary care affects assignment of Medicare beneficiaries to accountable care organizations (ACOs). DATA SOURCES: Medicare claims for a random 5 percent sample of 2009 Medicare beneficiaries linked to American Medical Association Group Practice data identifying provider groups sufficiently large to be eligible for ACO program participation. STUDY DESIGN: We calculated the fraction of community-dwelling beneficiaries whose assignment shifted, as a consequence of including post-acute E&M services, from the group providing their outpatient primary care to a different group providing their inpatient post-acute care. PRINCIPAL FINDINGS: Assignment shifts occurred for 27.6 percent of 25,992 community-dwelling beneficiaries with at least one post-acute skilled nursing facility stay, and they were more common for those incurring higher Medicare spending. Those whose assignment shifted constituted only 1.3 percent of all community-dwelling beneficiaries cared for by large ACO-eligible organizations (n = 535,138), but they accounted for 8.4 percent of total Medicare spending for this population. CONCLUSIONS: Under current Medicare assignment rules, ACOs may not be accountable for an influential group of post-acute patients, suggesting missed opportunities to improve care coordination and reduce inappropriate readmissions.

Health care of youth aging out of foster care.

Youth transitioning out of foster care face significant medical and mental health care needs. Unfortunately, these youth rarely receive the services they need because of lack of health insurance. Through many policies and programs, the federal government has taken steps to support older youth in foster care and those aging out. The Fostering Connections to Success and Increasing Adoptions Act of 2008 (Pub L No. 110-354) requires states to work with youth to develop a transition plan that addresses issues such as health insurance. In addition, beginning in 2014, the Patient Protection and Affordable Care Act of 2010 (Pub L No. 111-148) makes youth aging out of foster care eligible for Medicaid coverage until age 26 years, regardless of income. Pediatricians can support youth aging out of foster care by working collaboratively with the child welfare agency in their state to ensure that the ongoing health needs of transitioning youth are met.

Fee-for-service will remain a feature of major payment reforms, requiring more changes in Medicare physician payment.

Many health policy analysts envision provider payment reforms currently under development as replacements for the traditional fee-for-service payment system. Reforms include per episode bundled payment and elements of capitation, such as global payments or accountable care organizations. But even if these approaches succeed and are widely adopted, the core method of payment to many physicians for the services they provide is likely to remain fee-for-service. It is therefore critical to address the current shortcomings in the Medicare physician fee schedule, because it will affect physician incentives and will continue to play an important role in determining the payment amounts under payment reform. This article reviews how the current payment system developed and is applied, and it highlights areas that require careful review and modification to ensure the success of broader payment reform.

The right patient.

This article offers professional opinions and advice on how physicians should prepare in order to protect themselves and their practices during this turbulent time in healthcare reform. This article presents real-life scenarios to help physicians understand what they may face and what actions they should take in anticipation of the future in healthcare. The article focuses on the concept of "the right patient," defining the characteristics of patients that benefit the financial aspect of a practice and those who do not. Its purpose is not to encourage physicians to deny care to patients who are poorly insured or uninsured, but to guide in the establishment of a smart and safe balance between the two. Strategies are discussed on how to attract the right patient and what these patients mean to the practice. The importance of practice marketing is also highlighted, along with an emphasis on the necessity of change in order to survive in the future healthcare environment.