JustCare

Tag: Quality

  • Traditional Medicare offers better home care benefits than Medicare Advantage

    Traditional Medicare offers better home care benefits than Medicare Advantage

    If you have Medicaid or can afford supplemental coverage to fill gaps in traditional Medicare, here’s another reason to think twice before signing up for a Medicare Advantage plan. Researchers at Brown University’s School of Public Health have found that Medicare Advantage plans do not offer the high quality home health care benefits that traditional Medicare offers. Traditional Medicare home health care services are better, they report in JAMA Network.

    People in traditional Medicare, overall, have access to far higher quality providers than people in Medicare Advantage plans. Last year, researchers at Brown University found that traditional Medicare offers higher quality skilled nursing facility benefits than Medicare Advantage plans. Medicare Advantage plans contract with poorer quality providers.

    Of course, people in good health need not be too concerned about the quality of care their health insurance offers them. But, all of us can be hit by a car, or slip and fall, or otherwise develop a costly condition at any time. So, it’s important to pick a Medicare plan that will meet your needs in the long-term.

    Unfortunately, data about the quality of care in particular Medicare Advantage plans is not available. But, the Brown University researchers found that people with costly health conditions were more likely to leave their Medicare Advantage plans and enroll in traditional Medicare. That’s another sign that Medicare Advantage plans are not meeting people’s needs when they need costly care.

    For their home health care study, the researchers analyzed data from 4.4 million people who received home health care. They could not independently assess the quality of the home health agencies serving people in Medicare Advantage plans. Instead, they determined quality based on star ratings, which can be seriously flawed. They found a “significantly” greater likelihood of getting high-quality care in traditional Medicare than in Medicare Advantage. Consequently, people in Medicare Advantage plans may suffer negative health outcomes.

    The researchers posit that Medicare Advantage plans save money by contracting with lower quality home health care agencies, just as they save money by contracting with lower quality skilled nursing facilities. Unfortunately, the Centers for Medicare and Medicaid Services does not factor in the quality of home health care agencies in a plan’s network when determining a Medicare Advantage plan’s star rating.

    The Kaiser Family Foundation has also looked at the quality of providers in Medicare Advantage plans and found that people in these plans are less likely to be able to use centers of excellence when they have cancer.

    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:

  • Before choosing a nursing home, check out Nursing Home Inspect

    Before choosing a nursing home, check out Nursing Home Inspect

    If you are looking into nursing home options, Pro Publica has an online tool worth exploring, Nursing Home Inspect. The tool relies on federal government inspection reports to spotlight nursing homes with serious deficiencies. It also shows the average fines paid by nursing homes and the number of times nursing homes have had payments suspended on new admissions as a result of deficiencies.

    The information on Nursing Home Inspect comes from the Centers for Medicare and Medicaid Services. CMS collects data on all Medicare and Medicaid certified nursing homes. And, you can search nursing home inspection reports in any number of ways, including by key word and by state.

    You can compare the nursing homes in a state based on an array of measures. For example, you can see all nursing homes in a state with serious deficiencies that put patients at immediate risk of harm. And, serious deficiencies abound in many states. Click here for a summary of Nursing Home Inspect’s state-by-state breakdown.

    You can take a deep dive into each nursing facility. Nursing Home Inspect includes information on whether a nursing home is for-profit or non-profit, the number of beds, the amount it has been fined in the last three inspection cycles and the degree of severity of its deficiencies. It also indicates whether a nursing home is a “Special Focus Facility.” These nursing homes have serious quality deficiencies that CMS is focused on addressing. It is likely wise to stay away from these facilities.

    Some states are more proactive than others at issuing fines on nursing homes with deficiencies. You can find out which states are more and less proactive and what the average fine is in a state.

    If you simply want to know which nursing homes in a state have the worst records, Nursing Home Inspect provides you with a list of the 20 nursing homes with the most fines and the 20 nursing homes with the greatest number of serious deficiencies.

    Here’s more from Just Care:

  • What are Accountable Care Organizations?

    What are Accountable Care Organizations?

    Medicare has been experimenting with new payment models to bring down health care costs, improve health care quality and promote healthy communities. One payment model launched in 2013 is a “shared-saving program” that involves “Accountable Care Organizations.” What are Accountable Care Organizations (ACOs)?

    ACOs are groups of doctors and/or hospitals, home health agencies and nursing homes that have contracted with  the Centers for Medicare and Medicaid Services (CMS) to coordinate patient care in ways that reduce health care spending and promote quality. If they succeed at lowering costs, they increase their revenues; they share in the savings. ACOs respond to the belief that hospitals and doctors need better incentives to keep patients healthy, improve care quality and reduce costs.

    People enrolled in traditional Medicare can also be enrolled in ACOs. According to the HHS Office of the Inspector General (OIG), those enrolled in an ACO tend to be older and have more health risk factors than the typical person with Medicare.

    If you are enrolled in traditional Medicare and see a doctor who participates in an ACO, you are automatically enrolled in an ACO. Your doctor will be coordinating your care with other doctors and health care providers in the ACO. But, you are also free to go outside the ACO for your care, like everyone with traditional Medicare.

    Unlike a Medicare HMO or other Medicare Advantage plan, in an ACO your care is coordinated, and you are covered for care from virtually any doctor or hospital in the U.S. For more information from CMS on ACOs, click here.

    There are 9.7 million people with Medicare currently enrolled in 428 ACOs around the country. In an attempt to determine whether they are getting better care at a lower cost, the HHS OIG studied databases between 2013 and 2015, the first three years of the ACO program. And, the OIG found that “most of them” reduced spending, with total net spending reduction of nearly $1 billion. The OIG also found that they improved quality of care based on CMS quality measures.

    To determine whether an ACO improves quality of care, CMS looks at how well the ACO coordinates care, the patient experience, the delivery of preventive care and treatment of at-risk populations. The OIG found that, among other things, the best-performing ACO’s reduced the number of hospital readmissions within 30 days and conducted patient screenings for future fall risks as well as depression screenings and follow-up plans.

    The highest-performing ACOs lowered spending by an average of $673 per individual compared to other ACOs, which show an increase in per-person Medicare spending.

    Here’s more from Just Care:

  • Medicare and Medicaid are more cost effective than commercial insurance

    Medicare and Medicaid are more cost effective than commercial insurance

    In his latest post for the New York Times, Austin Frakt makes the case that both Medicare and Medicaid for all would bring down health care spending and deliver as good care as commercial insurance (private insurance). In short, Medicare and Medicaid pay less than private insurers for the same care and are more cost effective.

    To establish the cost-effectiveness of Medicare and Medicaid, Frakt looks at three studies. A JAMA Internal Medicine study of 26 health care services that have been deemed unnecessary or “low value” finds that they represent about 2.7 percent of Medicare spending. A second study compares Medicare and commercial insurance spending on low-value services in 2009, 2010 and 2011. That study finds that both types of insurance cover these services at about the same frequency.

    The third study, also in JAMA Internal Medicine, compares the delivery of low-value care for patients with Medicaid or who are uninsured and patients with commercial insurance, between 2005 and 2011. It too finds the same rate of low-value care for both patient populations. It also finds the same rate of high-value care.

    Frakt posits that while you might think that doctors perform more services on patients whose insurers pay them more, these three studies suggest that it is not the case. Rather, it appears that doctors generally treat patients the same regardless of the insurer paying for their services. The differences in the rate of delivery of low-value care stem primarily from local practice patterns and not which insurer is paying for the care.

    To be clear, your particular health insurance may not affect the care your doctors will deliver. But, it will determine your access to care–which doctors and hospitals will see you with that insurance. So, the quality of your care through Medicaid may be as good as the care you receive through private insurers. But, with Medicaid, you may struggle to access that care. (Click here to learn why Medicaid matters to all of us.)

    Here’s more from Just Care:

  • UnitedHealth charged with enrollment fraud

    UnitedHealth charged with enrollment fraud

    Fred Schulte of Kaiser Health News reports that UnitedHealth, the largest provider of Medicare Advantage plans–commercial insurers expected to deliver Medicare benefits–has been hiding enrollment fraud and other wrongdoings, according to a whistleblower’s claims in a recently unsealed lawsuit. By so doing, it was able to improperly collect almost $1.5 billion in Medicare bonus payments.

    If UnitedHealth is found to have been engaged in fraud, what penalties will it incur? This is not the first fraud suit against UnitedHealth. UnitedHealth, among other insurers offering Medicare Advantage plans, has been charged with involvement in a range of behaviors to increase their revenues that may run afoul of the law. They face at least six cases brought under the Federal False Claims Act.

    In May, the New York Times reported on a lawsuit filed by a former employee of UnitedHealth charging that the company was improperly making its members out to be sicker than they were in order to receive additional payments from Medicare. The Justice Department is investigating the matter and has said it intends to sue UnitedHealth.

    The new whistleblower lawsuit alleges that UnitedHealth was aware that at least one of its agents was forging signatures on Medicare Advantage enrollment forms to make it appear that the company had more members than it actually did and generate more revenues. It says that another agent was offering kickbacks to get people to sign up for a Medicare Advantage plan.

    UnitedHealth allegedly hid these activities and hundreds of member complaints filed against it in order to keep its high Medicare ratings, which we have previously reported are not to be trusted. (You can read our post here: Medicare star ratings of Medicare Advantage plans a farce.)  It reported only 257 of 771 serious complaints in its files. By hiding these quality indicators, UnitedHealth also collected $1.4 billion in quality bonuses from Medicare.

    The whistleblower suit by James Mlaker and David Jurczyk claims that UnitedHealth kept two databases, one with the full set of complaints and one with an abbreviated list of complaints that it shared with the Centers for Medicare and Medicaid Services. It further claims that UnitedHealth either dismissed serious complaints or otherwise discounted them to mislead Medicare.

    Aside from these and other allegations of fraud and other misconduct, the Medicare Payment Advisory Commission (MedPAC) has found that Medicare Advantage plans are less cost-effective than traditional Medicare. Taxpayers continue to spend more per person in Medicare Advantage plans than in traditional Medicare.

    Here’s more from Just Care:

  • Even without ACA repeal, quality of care at risk

    Even without ACA repeal, quality of care at risk

    The Republican leadership’s ACA repeal bill is dead for now, but quality of care in the U.S. is still at risk. In an interview for KPBS.org, Donald Berwick, M.D., president emeritus of the Institute for Healthcare Improvement and former head of the Centers for Medicare and Medicaid Services, explains the importance of ACA initiatives to improve health care quality. Even without ACA repeal, there’s reason for concern that the Trump Administration will give these initiatives short shrift.

    As head of the department of Health and Human Services, Tom Price could do a lot to undermine the quality improvement programs included in the Affordable Care Act.  Will Secretary Price, for example, honor the ACA’s requirement that government collect health care data, develop evidence-based measures of health care quality, and give people a better understanding of differences in care provided by doctors, hospitals and nursing homes? Will the Trump Administration promote health care transparency or leave us in the dark when doctors and hospitals perform poorly, putting patients at risk.

    Beyond supporting systems for measuring and reporting quality of care, what will become of ACA-funded initiatives that promote significant quality improvements among doctors and hospitals? For example, the ACA’s $500 million Partnership for Patients helps reduce hospital-acquired conditions, such as pressure ulcers people get in hospital from not moving, and blood clots. According to Berwick, that initiative alone has saved “tens of thousands of lives and billions of dollars.”

    Similarly, Medicare’s hospital five-star rating system and financial penalties on hospitals that performed poorly on certain quality measures, (for example, hospitals with high readmission rates within 30 days of patients being discharged or with high numbers of patients acquiring infections unnecessarily,) have helped to promote better care. And, they have helped Americans appreciate that some hospitals perform better than others. Will the Administration dedicate needed funds to these programs?

    The Republican leadership has not shown much appreciation for the value of health care transparency and incentives to drive quality improvements. How far backwards will they push our health care system even without ACA repeal?

    Here’s more from Just Care:

  • Which health plan should you choose if you’re ill?

    Which health plan should you choose if you’re ill?

    Which health plan should you choose if you’re ill? Given all the talk about competition in the health care marketplace, you’d think that Medicare and other health plans plans would be out there telling you that they offer the best doctors and hospitals at the best cost for people with specific conditions, e.g. cancer, stroke, or multiple chronic conditions. But, they do not.

    Commercial health plans, including Medicare Advantage plans for people with Medicare, make money on healthy people. They don’t want you to know about the quality of the costly care they offer, so they tell you very little about health outcomes for their patients with costly and complex conditions. If you Google, “best Medicare health plan for cancer patients,” see what comes up.

    And, to help keep the number cancer patients who enroll in their plans down, commercial health plans–for people with Medicare and working people–generally do not include the best cancer doctors or the best cancer hospitals, such as Memorial Sloan Kettering Cancer Center or M.D. Anderson, in their networks. Kaiser Health News reports that the Affordable Care Act health plans are not including specialty cancer centers in their networks and not covering out-of-network care.

    Of course, the data suggest that where you get your care can matter a lot, especially when you’re sick. One recent report showed that people who went to high quality hospitals after a heart attack lived nine to fourteen months longer than people who did not.

    What can you do to protect yourself?  As we explain in “Three reasons why you can’t pick a health plan that’s right for you,” If you are eligible for Medicare and can afford the upfront costs, consider enrolling in traditional Medicare with supplemental coverage. You may pay more for your coverage up front. But, if you end up needing costly care, it will likely save you money. And, traditional Medicare offers the greatest opportunity for coverage from the doctors and hospitals you want to use. If you go the commercial health plan route, here are two tips for choosing a health plan.

    Here’s more from Just Care: 

  • The VA health system: Best in class and under fire

    The VA health system: Best in class and under fire

    Some might say with good reason that the Veterans’ Health Administration or the “VA” health system is best in class–indeed, Phillip Longman, senior editor at the Washington Monthly, has written extensively about the VA, calling it “The best care anywhere.” The VA offers a national health care system with the government owning most of its care facilities and employing its 311,000 doctors and other staff. What makes the VA system so good and why is it under fire?

    The VA system is the largest health care system in the U.S., covering 6.7 million veterans through a network of about 150 hospitals and more than 800 outpatient clinics. Different veterans are eligible for different levels of coverage, with veterans who were engaged in combat eligible to get the highest level of coverage. The VA does not charge a premium for coverage, but depending upon the nature of their service and injuries, veterans may pay copays. Copays tend to be low for veterans who sustained serious injuries while on active duty and are unable to find employment. Copays can be quite high for other veterans.

    The VA has been praised as a model for delivery of integrated care for people with complex and costly conditions. Doctors employed by the VA can rely on an electronic medical record system that allows them to coordinate care; they use data to drive good health care outcomes. Not surprisingly, the VA gets high marks on quality relative to the private sector. And, its doctors have the expertise needed to treat a population of people with very serious conditions.  Just one example of the V.A.’s expertise–a 2005 fall-prevention program has led to many fewer veterans falling and getting a hip fracture. By contrast, most hospitals don’t provide guidance to discharged patients who were hospitalized for a hip fracture resulting from a fall, let alone collect follow-up data.

    But, at the same time, the VA, like all health care systems in the U.S., is experiencing a doctor shortage. It has too few doctors and other providers to treat the growing pool of veterans, including both aging Vietnam War veterans and younger Iraq and Afghanistan veterans–and wait times to see primary care doctors are excessive. A 2014 report by the VA Office of the Inspector General documents the issues.  And, an April 2016 GAO report finds that wait times for primary and specialty care continue to be a serious concern and that the VA appointment scheduling policy needs upgrading.

    To address long waits for care, just a few weeks ago, a bi-partisan Congressional Commission has made a series of recommendations. Not surprisingly, the conservatives on the Commission, along with outsiders like the Koch brothers and Donald Trump, would like to privatize the VA over the next two decades. Veterans are strongly opposed.

    The Commission made many recommendations around infrastructure. Its biggest recommendation was to establish a new VHA Care System, expanding the pool of doctors and hospitals treating veterans with additional health care providers, from both government and the private sector. However, back in 2014 to address the long waits for care, Congress passed the Choice Act, which allowed veterans coverage for care from private doctors in certain situations. While this may sound good in theory, it did not work in practice. Indeed, wait times increased.

    For sure, more doctors and hospitals are needed to treat veterans. But, why would relying on the private sector be a solution now, when it did not work back in 2014? We all experience long wait times to see doctors. Moreover, most primary care doctors outside the VA are not trained to treat war veterans And, commercial care brings with it large out-of-pocket costs. As Philip Longman says, “Offering unlimited, unmanaged choice of doctors and treatments would not only lead to dangerously fragmented care, it would also cost so much that in the real world, it would be a political non-starter and thus limit choice.”

    There are other ways to reduce wait times for treatment. Some propose that the VA allow nurses with special expertise to practice without supervision from doctors, which is already permitted in 20 states. Or, as Longman proposes, in places where it lacks capacity, the VA could identify and contract with skilled outside doctors in an integrated fashion that allowed these providers to use the same electronic medical system as the VA doctors.

    Longman sees the VA as our opportunity to move the U.S. towards a better, more cost-effective health care system. In his words, “The VA model of care, with its emphasis on integration, prevention, and evidence-based, cost-effective care, is also in the forefront of where the rest of the U.S. health care needs to go. If we lose the VA, the cause of real healthcare delivery system reform will be set back by at least another generation, with incalculably dire consequences health and finances of the American population.” Of course, moving towards a VA system for all threatens Aetna, Blue Cross and UnitedHealthcare among other big stakeholders in our health care system. And, that’s precisely why the VA system is at risk.

    Here’s more from Just Care:

     

  • Link between hospital boards and quality of care

    Link between hospital boards and quality of care

    Quality of care in U.S. hospitals remains a serious concern. A good number of hospitals do not follow evidence-based practices a lot of the time. The data suggests a link between hospital boards and quality of care. So where do hospital boards stand on quality of care? It’s not a top priority for many, according to a 2010 Health Affairs article by Ashish Jha and Arnold Epstein.

    Delivering health care is costly and hospitals have increasingly become big businesses, with directors focused heavily on financial performance. Much like for-profit hospitals, non-profit hospitals are looking hard to control costs. So, where does the mission of hospitals to provide good care to their patients and the communities they serve fit in? (Did you know that most hospitals offer financial assistance and that non-profit hospitals must work with their local communities to prioritize local needs?)

    A hospital’s board of directors, which must oversee hospital performance and set the strategic direction of the hospital, has a large role to play in ensuring that quality remains a top priority. A 2006 report in the Joint Commission on Accreditation of Healthcare Organizations’ Journal on Quality and Safety showed a link between patient mortality and the hospital board’s engagement in quality. There was a statistically meaningful difference between mortality rates in hospitals more engaged in quality and those less engaged, with the evidence suggesting that the board’s engagement can improve hospital quality.

    Jha and Epstein surveyed hospital board chairs from among the 85 percent of acute care hospitals that are non-profit. They found that higher quality hospitals tended to have boards which made quality a priority.

    Of the 722 hospital board chairs who responded to the Jha-Epstein survey, almost three out of four said that their boards had moderate to substantial expertise in quality of care. The reported rate of expertise at high-performing hospitals was 87 percent as compared with a rate of 66 percent at low-performing hospitals.

    Boards might be better able to ensure hospital quality if they were trained in clinical quality. Based on the data, quality training appears to play a significant role. Fewer than one in three hospital boards received any training in clinical quality at the time of the Jha-Epstein study. Yet, of those that received training, 49 percent were in high-performing hospitals and 21 percent in low-performing hospitals.

    Boards might also put greater emphasis on quality performance to promote hospital quality of care. Almost seven in ten board chairs recognized the influence of the CEO on quality of care. Yet, fewer than half of the board chairs (44 percent) Jha and Epstein surveyed saw quality performance as one of the two top criteria for evaluating CEO performance.

    Here’s more from Just Care: