JustCare

Tag: CMS

  • Hospital rating systems are all flawed

    Hospital rating systems are all flawed

    You should choose your hospital carefully, but do not rely on a hospital rating system. A new paper in the New England Journal of Medicine finds that all hospital rating systems are flawed. While the researchers did not give any hospital rating system an F, they did not give any an A grade either.

    Most noteworthy, the researchers gave the Centers for Medicare and Medicaid Services’ (CMS) Hospital Star Ratings a C grade, meaning it is a “mediocre rating system” with a “fair bit of misclassification.” This comes as no surprise given that the HHS Office of Inspector General has recommended that CMS do a better job of data auditing to ensure hospitals are not inappropriately manipulating data or inaccurately reporting data.

    The researchers gave U.S. News & World Report a B grade, which was the highest grade. Leapfrog and Healthgrades received the lowest grades, C- and D+, respectively.

    The researchers found that every hospital rating system had shortcomings that could mean misreporting of performance. In some cases, quality measures were flawed. In other cases, data was not validated or methodologies were poor, without meaningful peer review.

    The researchers also pointed out that hospital ratings systems do not offer a good holistic evaluation. They explained that it is confusing at best to read that a hospital performs well on one measure and poorly on another. What is a person to do with this conflicting information?

    Of note, the researchers reported that most of the hospital data reported comes from the traditional Medicare program, a serious shortcoming, reflecting care provided to only one subpopulation. They recommended that data come from an all-payer database to better reflect hospital quality of care for all populations.

    How should you choose a hospital? It’s not easy to know which ones deliver the best care. You should probably avoid hospitals with low ratings. You should also try to avoid ones that Medicare fines because of high readmission rates, high infection rates or high numbers of patient injuries. You can look those hospitals up here. Your best bet may be to talk to your doctors about the hospitals in your community they recommend.

    Here’s more from Just Care:

  • Major problems with Medicare Plan Finder

    Major problems with Medicare Plan Finder

    Not long ago, advocacy groups called out the Centers for Medicare and Medicaid Services (CMS) for misleading the public about Medicare Advantage plans–private insurance plans that offer Medicare benefits–and steering people into them without providing appropriate warnings. Now, the Government Accountability Office (GAO) has issued a report highlighting major problems with the Medicare Plan Finder web site, which is supposed to help people compare Medicare plans.

    People should be able to know when they choose a Medicare plan what their out-of-pocket costs are likely to be and which doctors and hospitals they can use. But, the Medicare Plan Finder cannot provide them with this basic information. People with Medicare understandably struggle to get the information they need from the Medicare Plan Finder.

    Estimates of out-of-pocket costs are incomplete on the Medicare Plan Finder, so people cannot make a meaningful comparison between traditional Medicare and Medicare Advantage. People need to know that their maximum out-of-pocket costs can be as high as $6,700 in a Medicare Advantage plan and far higher if they use out-of-network doctors and hospitals. But, the Medicare Plan Finder does not highlight these costs. It does not make it easy for people to see that if they want to spend time with a family member outside of their community and need care, they may have to pay for all their care out of pocket if they join a Medicare Advantage plan.

    To find out whether the doctors and hospitals you want to use are in a Medicare Advantage plan, call them directly and ask. You can also visit the Medicare Advantage plan’s web site. Always call the plan to confirm. Medicare Advantage plan provider directories are wildly inaccurate. Provider information is not on the Medicare Plan Finder.

    In traditional Medicare, people with supplemental coverage have minimal costs. If they do not have Medicaid or retiree benefits to provide this coverage, they need to buy this “Medigap” coverage. And, they need to know its cost and the specific benefits covered. That information is not available on the Medicare Plan Finder site.

    Note, the Medicare Handbook is also misleading. Call your SHIP (State Health Insurance Assistance Program) for free help choosing a Medicare plan.

    Medicare for All, an improved traditional Medicare, proposed by Senator Bernie Sanders and others, guarantees everyone coverage from virtually all doctors and hospitals, without premiums, deductibles and copays, or the need for supplemental coverage. It would save people money on their health care, without forcing them to give up the choice of doctors and hospitals they most value. As important, it would not force people to try to navigate a sea of rules and constantly changing health plans and guess whether there’s a health plan that may meet their needs. It also would not ration care based on ability to pay.

    If you support Medicare for All, please let Congress know. Sign this petition.

    Here’s more from Just Care:

  • Medicare Advantage plans unaccountable for billions in overcharges

    Medicare Advantage plans unaccountable for billions in overcharges

    Past government audits reveal that Medicare Advantage plans have overcharged the federal government tens of billions of dollars since their inception. Recent government data show that Medicare Advantage plans have overcharged the federal government an average of $10 billion a year for the last three years. What’s worse, they have been unaccountable for these overcharges.

    Medicare Advantage plans have served a healthier population than traditional Medicare but have billed the federal government as if they were serving a less healthy population. They have pocketed tens of billions of dollars they were not due. And, they have not returned almost any of the money.

    The Kaiser Family Foundation reports that the federal government will try to recoup a tiny fraction of those overpayments. In the past, it has not been successful. For reasons that are inexplicable the Center for Medicare and Medicaid Services (CMS) has gotten only about $14 million of more than $100 billion in overpayments returned. The $14 million is less than it costs to perform the audits.

    The federal government pays Medicare Advantage plans based on the health status of their enrollees, their “risk score.” As a result, Medicare Advantage plans have found a variety of ways to increase their enrollees’ risk scores. The government overpays Medicare Advantage plans whenever they claim that their enrollees are less healthy than they in fact are, or when they charge the federal government for treating more serious conditions than they can demonstrate their enrollees have. Then, these health plans claim that any attempts to reclaim these overpayments will hurt their enrollees.

    For years, CMS trusted the Medicare Advantage plans to provide accurate information about their enrollees’ health under an “honor system.” Then, when it saw that it was overpaying them, it instituted a system for validating these risk scores. Still, CMS appears either unable or unwilling to hold Medicare Advantage plans accountable.

    In the past, CMS has only audited a handful of Medicare Advantage plans in a given year. And, it has asked for refunds only for particular patients. So, it has recouped meaningless sums. Until recently, CMS did not disclose much of this information to the public. Fortunately, the Center for Public Integrity sued CMS under the Freedom of Information Act for the information, and it was made public.

    Now, CMS proposes to extrapolate from a random sample of 200 patients to the full number of enrollees in a Medicare Advantage plan. That could lead to refunds of tens of millions of dollars from a single Medicare Advantage plan. This is a controversial but common technique when investigating medical fraud. But, Medicare Advantage plans have challenged it successfully, avoiding accountability for systematic overcharges.

    This year, CMS is starting audits for 2014 and 2015, 30 per year, targeting about 5% of the 600 Medicare Advantage plans annually. But, it is unclear whether it will back down from requiring refunds under health insurance industry pressure. If it does so for the 2011-13 period, taxpayers would lose more than $500,000,000 in overpayments. And, Congress should have even more reason to question the value of Medicare Advantage plans.

    Here’s more from Just Care:

  • Choose your hospice carefully

    Choose your hospice carefully

    The HHS Office of the Inspector General just issued two scathing reports on the Medicare hospice program. It found that nearly one in five hospice agencies suffered from serious deficiencies that put patient health and safety at risk. And more than four in five had at least one deficiency. Choose your hospice carefully.

    The Medicare hospice benefit can be extremely valuable to patients who choose palliative or comfort care rather than curative care at the end of life. Usually, care is provided in the person’s home. But, it can also be provided in an assisted living facility or skilled nursing facility. Some hospices have their own hospice inpatient unit.

    But, not all hospice care is the same. We do not know which specific hospice agencies the OIG found suffered from serious deficiencies or how many of the 1.5 million Medicare patients in hospice are endangered. The OIG examined only a small number of cases. It described a case in which a dying man’s feeding tube had maggots growing on it. And, it reported on a patient with Alzheimer’s going without appropriate wound care, which caused her to need her leg amputated.

    The Centers for Medicare and Medicaid Services (CMS), however, apparently does not have adequate authority to hold these companies to account when they cause harm to patients. CMS’ only available penalty is to end its contract with hospice agencies, which CMS has not chosen to do. Consequently, hospice agencies can cause harm to patients with apparent impunity. The OIG recommends that CMS have greater legal authority to penalize these hospice agencies.

    The OIG recommends Congress give CMS the authority to impose fines on hospice agencies, authority CMS already has for nursing facilities. That said, CMS does little to use that authority with nursing homes. And, why is CMS not simply terminating contracts with the facilities that put patients at risk because of their serious deficiencies?

    Moreover, why isn’t CMS flagging the agencies that have serious deficiencies on Hospice Compare, a government tool to help people choose a hospice agency. CMS has chosen not to publish state agency reports showing deficiencies because “they may be misleading.” CMS claims that state reports on hospice violations should not be available on Hospice Compare. As of now, survey reports from accrediting organizations, such as NCQA, the National Committee for Quality Assurance, cannot be publicly disclosed. But, that may change.

    CMS argues that Medicare-certified hospices are required to meet federal health and safety standards that keep patients safe. But, it clearly is not ensuring that they do. Before you choose a hospice agency, do your homework. Check with your state to learn about deficiencies the state has found with hospice agencies.

    Here’s more from Just Care:

  • Medicare may cover acupuncture for lower back pain

    Medicare may cover acupuncture for lower back pain

    The Washington Post reports that, under a new proposal, the Centers for Medicare and Medicaid Services (CMS) would permit Medicare to cover acupuncture for lower back pain in limited situations. Until now, Medicare has not deemed acupuncture a covered service for treatment of any condition.

    Lower back pain is a common condition impairing the quality of life for millions of Americans. And, it can lead to disability. The cost of treating chronic pain in the US is several hundred billion dollars each year. What causes back pain? A number of factors, including genetics, psychological, and environmental. Consequently, determining how to manage it can be difficult.

    Acupuncture has been a source of healing in Asia for thousands of years. But, the evidence is not clear that acupuncture can help lower back pain. Acupuncture may only be a placebo, a treatment that offers no therapeutic effect; though, placebos can offer a psychological benefit.

    The CMS proposal would offer acupuncture to patients with lower back pain in clinical trials funded by the National Institutes of Health.

    The American College of Physicians supports testing alternatives to prescription drugs, particularly opioids, for lower back pain. These alternatives include yoga, exercise and acupuncture.

    The Agency for Healthcare Research and Quality found that people with lower back pain who receive acupuncture may see some improvements in function and feel less pain in the short term.  However, AHRQ did not find long-term improvements in function or pain.

    A meta-analysis in the Pain Practice journal found that, for short-term outcomes, acupuncture showed significant improvement over a placebo for back pain. Over the long term, however, acupuncture outcomes were inconsistent. The study did not determine whether the overall benefit of acupuncture is meaningful and cost-effective.

    For back pain, Medicare covers some drugs, as well as injections, braces and chiropractic care. In some cases, it covers implanted neurostimulators.

    Here’s more from Just Care:

  • Evidence suggests privatized Medicaid long-term care may put people at serious risk

    Evidence suggests privatized Medicaid long-term care may put people at serious risk

    The US health insurance system has become increasingly privatized. One big trend is in the Medicaid program. More than two dozen states have contracted with for-profit health insurance companies to deliver home and community-based services to people with Medicaid, crowding out mission-driven non-profit providers. The available evidence suggests that privatized Medicaid long-term care may put people at serious risk.

    Researchers at the Claude Pepper Center express concern both for people with Medicaid and for taxpayers. These large commercial insurers need to drive profits. And, in the health care space, they can do so relatively easily by delaying and denying people needed care. What’s happening to health care access, quality and costs for people with Medicaid needing long-term services and supports in states that have moved to for-profit Medicaid long-term care?

    Today, more than 1.7 million people with Medicaid are in managed long-term care (MLTC) programs operated by for-profit companies or private equity firms. There is precious little evidence to suggest that these programs are more efficient or deliver better care than the non-profits which had been delivering LTC services. There is simply a mindset among some policymakers that for-profit competition is the better model.

    What do we know? AARP has assessed states with the best LTC programs for people with Medicaid. And, the states which rely most heavily on for-profit long-term care (MLTC) rank at the bottom. Two studies conducted in Texas, which has extremely high MLTC enrollment, found poor quality and a system in need of major intervention. Access to network doctors was inadequate. And, the state has little if any ability to monitor or assess performance by the for-profit insurers.

    The federal government, in partnership with powerful corporations who wield undue influence in Congress and in the states, has pushed this move away from the non-profit model of LTC and towards the for-profit model. The GAO has investigated and found serious cause for concern and a lack of needed oversight. The Centers for Medicare and Medicaid Services (CMS) is doing little to ensure appropriate oversight.

    According to AARP, Washington, Oregon, Vermont, Minnesota, Arkansas, Wisconsin and Colorado have the best long-term care programs. None are MLTC. These states should resist a move to for-profit managed long-term care.

    Here’s more from Just Care:

  • Medicare will identify 400 nursing homes with serious health and safety violations 

    Medicare will identify 400 nursing homes with serious health and safety violations 

    It is a travesty how little information is available to Americans about the quality of particular health care providers. We spend a tremendous amount of money on health care. And, we often put our lives in the hands of health care providers. Commercial health insurers rarely if ever disclose the bad actors. Under Senate pressure, Medicare is naming an additional 400 nursing homes with serious health and safety violations.

    Earlier this month, Senators Bob Casey (D-PA) and Pat Toomey (R-PA) released a report on nursing homes with serious health and safety violations. The report focuses on poor federal oversight of hundreds of nursing homes found by state survey agencies to abuse and neglect patients. In some of these facilities, investigators found residents were left without proper nutrition or languishing in filthy conditions. In other facilities, residents were physically abused and sexually assaulted. Consequently, in some instances, residents have died prematurely.

    Given budget cuts, the report asks whether Medicare has the needed resources to properly oversee and inspect these nursing homes and help improve conditions.

    Even though state agencies have flagged these nursing homes for their poor performance, the Centers for Medicare and Medicaid Services (CMS) has not identified them to the public nor has CMS acted to ensure they improve their quality. As a result of limited resources, CMS has named only 88 poor-performing nursing homes as “Special Focus Facilities,” SFF, to which it is directing its attention.  But, 400 additional nursing homes qualify as SFF because they have been found to have a “persistent record of poor care.”

    Since CMS has not been treating these 400 nursing homes as in need of special oversight, it had not identified them to the public. In the wake of the report’s release, however, the federal government has agreed to post a list of these 400 underperforming nursing homes.

    Ensuring the public has good quality information to make smart decisions about nursing homes is a priority of Congress.  The CMS Nursing Home Compare site offers some good information through its star-ratings. The 2,900 nursing homes with one star perform the poorest relative to the other nursing homes with star ratings.

    SFF participants do not have a star rating. Rather, they have a warning sign beside their names on Nursing Home Compare. Casey and Toomey’s report argues that the other 400 candidates for SFF also should have a warning sign by their names. Like the SFF participants, they should not have a star rating.

    If at all possible, avoid nursing homes that do not have five-star ratings. And, keep in mind that even they may have issues, though perhaps fewer than others. The Senators point out that almost 30 percent of the poor performing homes they identified had two-star ratings.

    For more good information on nursing homes, check out Informed Patient Institute. It gives both Nursing Home Compare and the US News and World Report ratings a B grade. You should also check out Pro Publica’s Nursing Home Inspect.

    Today, there are nearly 16,000 nursing homes, with 1.3 million residents. Fewer than one percent of them reside in a SFF nursing home or the 400 additional nursing homes that are SFF candidates.

    Here’s more from Just Care:

  • Congress should level the playing field between traditional Medicare and Medicare Advantage

    Congress should level the playing field between traditional Medicare and Medicare Advantage

    To protect people with Medicare and give them meaningful choice, Congress needs to level the playing field between traditional Medicare and Medicare Advantage. Unless traditional Medicare and Medicare Advantage offer the same benefits under the same terms, people cannot make a meaningful choice between them or protect themselves from Medicare Advantage plans that may threaten their health and safety.

    In a previous post, I compiled information from the Office of the Inspector General (OIG), the Government Accountability Office (GAO) and the Centers for Medicare and Medicaid Services (CMS) revealing that some Medicare Advantage plans are threatening the health and safety of their members. But, we do not know specifically which Medicare Advantage plans remain a danger for people with Medicare. All we know is that CMS may award five-star ratings to ones it has found to jeopardize people’s health and safety, and MedPac currently finds these star ratings not trustworthy.

    Yet, many people who want to leave their Medicare Advantage plans for traditional Medicare may not have that choice. A new Health Affairs paper by David Meyers et al., Brown University School of Public Health, reveals that people who want to leave their Medicare Advantage plan for traditional Medicare may not be able to buy supplemental coverage, Medigap, to fill coverage gaps. Because, unlike Medicare Advantage, traditional Medicare does not have an out-of-pocket cap, supplemental coverage is critical to protect people’s health and financial well-being.

    The paper explains that people with higher health care needs are more likely to want to leave their Medicare Advantage plans. But, these same people are the ones least likely to be able to switch to traditional Medicare because it lacks a catastrophic cap and there is no guarantee they can buy supplemental coverage.

    There are some federal protections that guarantee people the right to buy Medigap when they first enroll in Medicare and within one year of enrolling in a Medicare Advantage plan. But, other than during those times, in all but eight states, insurance companies selling Medigap coverage that fills gaps in Medicare can refuse to sell people this coverage or hike up premiums to the point that they are unaffordable.

    The information from the Office of the Inspector General (OIG), the Government Accountability Office (GAO) and the Centers for Medicare and Medicaid Services (CMS) on the health and safety risk of Medicare Advantage plans is likely the tip of the iceberg. They have also found that more CMS oversight and audits of these plans is needed. Moreover, it appears that CMS has not been able to get Medicare Advantage plans to comply with federal regulations over several years.

    To protect people with Medicare enrolled in Medicare Advantage, Congress should  take immediate action. It should impose a cap on out-of-pocket costs in traditional Medicare as well as ensure that Medigap plans are all community-rated and guaranteed issue.

    Here’s more from Just Care:

  • People with Medicare and Medicaid in Special Needs Plans at extra risk

    People with Medicare and Medicaid in Special Needs Plans at extra risk

    A paper in Health Affairs by Marc A. Cohen et al. explains that people with Medicare and Medicaid, “dual-eligibles,” enrolled in commercial Medicare Special Needs Plans, a type of Medicare Advantage plan, are now at extra risk. A new guideline by the Center for Medicare and Medicaid Services (CMS) severely restricts their right to disenroll from these plans. Yet, the data show that dual-eligibles with complex conditions may need to leave Special Needs Plans in order to get appropriate care.

    Dual-eligibles with complex conditions have been disenrolling at high rates from Special Needs Plans. And, it’s likely it’s because they are not getting the care they need. It’s hard to believe that dual-eligibles are jumping at the chance to leave their SNPs if they are getting the care they need. Changing health plans is never fun, always involves time and energy, and usually also stress and frustration.

    Keeping enrollees who choose to leave SNPs from disenrolling is not in these enrollees’ best interests. As of January 1, 2019, however, dual-eligibles may not leave their Special Needs Plan any month of the year, a protection they have always had. They must remain in their SNPs for at least three months, except during the Medicare Advantage Open Enrollment Period, between January and March of each year. Many states limit the disenrollment rights of dual-eligibles even further.

    The new guideline from the Centers for Medicare and Medicaid Services (CMS) supports the financial interests of Special Needs Plans (SNPs) that fail to provide good care to their enrollees. Cohen et al. explain that there is a high correlation between enrollees with complex conditions disenrolling from SNPs and low-quality SNPs. Another recent study showed high rates of disenrollment from Medicare Advantage plans for dual-eligibles with complex conditions.

    The new policy compromises the health of low income older adults and people with disabilities. It gives SNPs the ability to count on additional Medicare and Medicaid income that they previously had not been able to count on, even when they deliver poor care. Supporters of the new policy claim that it gives enrollees more time to adjust to the SNPs. Of course, if the SNPs are not serving their needs, it’s unclear why forcing enrollees to remain in the SNPs is helpful to them.

    To determine whether disenrollment from SNPs was associated with poor SNP performance, the paper’s authors looked at SNP quality measures. They found that the SNPs with poor performance were far more likely to see high disenrollment rates. Unfortunately, dissatisfied enrollees will no longer be able to leave as quickly as they had been able to.

    Here’s more from Just Care:

  • Medicare Advantage plan “honor system” can breed fraud

    Medicare Advantage plan “honor system” can breed fraud

    The federal government today pays commercial health insurance companies nearly $200 billion a year to provide Medicare benefits to the 20 million people now enrolled in Medicare Advantage plans.  How these commercial health plans spend that money is largely hidden from public view. An opinion piece in StatNews makes the case that the “honor system” in which Medicare Advantage plans operate is one that can breed fraud.

    Medicare Advantage plans, which are in the business of maximizing profits, have an incentive to spend as little as possible on patient care. The federal government pays them not based on the number of services they cover but rather a fixed or capitated rate per enrollee. What the Medicare Advantage plans don’t spend on patient care they get to keep. Not surprisingly, in 2018, the US Department of Health and Human Services Office of the Inspector General found widespread delays and denials of care in the Medicare Advantage program.

    To maximize profits, Medicare Advantage plans also have an incentive to claim that their patients are in poorer health than they in fact are. That drives up health care spending and hurts taxpayers. Several False Claims suits have been filed against insurers for doing just that. Recently, HealthCare Partners Holdings LLC settled a lawsuit and paid $270 million. It had been charged with overstating the health needs of its Medicare Advantage enrollees.  Another recent False Claims suit was filed against Sutter Health, a hospital system in California. It too was charged with overstating the health needs of its enrollees in order to generate higher government revenues and increase its profits.

    The Centers for Medicare and Medicaid Services (CMS) estimates that as much as 10 percent of the money it pays Medicare Advantage plans–$16 billion in FY 2016–is improper. The Government Accountability Office reports that CMS is not using the appropriate tools to detect these improper payments, suggesting that overpayments to Medicare Advantage plans could be far higher.

    The challenge is that CMS cannot easily detect fraud in these Medicare Advantage plans given the cloud of secrecy in which they operate. Usually, it takes a False Claims Act lawsuit by a whistleblower working at one of these companies to expose the fraud and lead the government to take action.

    Here’s more from Just Care: