medicaid programs

ALSO NOTED: IOM urges geriatrician pay increase; Kuhn takes over as Medicaid head; and much more...

Mon, 14 Apr 2008 06:59:50 -0400

> In an effort to make sure aging baby boomers get appropriate care, the Institute of Medicine is urging payers to support an increase in pay for geriatric specialists. Article

> With the departure of former head Dennis Smith, CMS deputy director Herb Kuhn has been named acting director of Medicaid programs. Article

> San Francisco's 911 system is under severe stress. In fact, a new investigation found that 27 percent of first responders have been arriving late on the scene of high-priority medical emergencies. Article

> Being a doctor has its privileges. According to a new report, doctors at UCLA hospitals who inappropriately viewed Britney Spears' medical files faced lighter penalties than hospital staffers. Article

And Finally... Now, some Aussies will have to watch out for the trash police. Article

CMS proposes more flexible Medicaid rules

Mon, 25 Feb 2008 06:59:58 -0500

CMS has proposed new rules that would give states more latitude in designing their Medicaid programs. The rules, which address provisions of the Deficit Reduction Act of 2005 and the Tax Relief and Health Care Act of 2006, would give states the ability to build Medicaid programs that work more like their local private health plans. CMS also has issued proposed regs, based on DRA provisions that will allow states to change premiums and cost-sharing rules. The new regs may mean that families with incomes of 100 to 150 percent of the poverty level may see some cost-sharing, while individuals with incomes of 150 percent or more of the poverty level could end up paying monthly premiums.

To learn more about the CMS regs:
- read this Healthcare Finance News article

Related Articles:
Community Health discloses further federal scrutiny. Article
Universal Health faces wider investigation. Article

DOJ: CHS submitted $27.5M in bad claims

Mon, 25 Feb 2008 06:59:57 -0500

The U.S. Department of Justice already had let the world know that hospitals run by Community Health Systems had submitted improper claims. Now, the government has attached a number to CHS's alleged indiscretions. The DOJ now says that three of facilities run by the Franklin, TN-based hospital operator submitted a total of $27.5 million in improper claims to a New Mexico-based indigent care program. The DOJ says that because CHS submitted the improper claims, the state then in turn submitted false claims to the federal government. CHS, for its part, continues to deny that it submitted any false claims, and is in talks with the feds.

The news follows a disappointing quarter for CHS, which just announced that it lost $88.3 million during Q4 '07 on revenue of $3.53 billion. That's down from profit of $53.6 million $1.1 billion in revenue for the same quarter in 2006.

To learn more about the allegations:
- read this Modern Healthcare piece (reg. req.)

Related Articles:
NY overpays providers by $26M. Article
Medicaid programs work on shared EMRs. Article

Providers face cuts under new budget proposal

Tue, 05 Feb 2008 06:59:57 -0500

While President Bush's proposed 2009 budget adds money to the Medicare and Medicaid programs, it also proposes to cut funding by a substantial amount over the next five years, raising protests from providers. The current budget proposal for fiscal 2009 includes $425 billion for Medicare, a $29 billion increase from 2008, and $217 billion for Medicaid, a boost of $13.7 billion from 2008. However, the proposal would take away what it gives over time. It includes legislative and administrative steps to cut Medicare by $183 billion and Medicaid by $17 billion over the next five years, cuts which would fall hard on hospitals and other providers. For example, the Medicare proposal would cut inpatient hospital payments by almost $4 billion in fiscal '09, and $64 billion over five years. This, of course, is going to generate violent resistance from hospital groups, who aren't known for taking this kind of thing lying down. Good luck getting this one through, Mr. President.

To learn more about the cuts:
- read this Modern Healthcare piece (reg. req.)

Related Articles:
Physician Medicare cut may be eliminated. Report
Senate proposes 6-month break from physician Medicare cut. Report
CMS program would base hospital pay on performance. Report

Judge dismisses IL conspiracy suit against MD groups

Fri, 18 Jan 2008 06:59:57 -0500

An Illinois judge has booted an antitrust suit brought against two Chicago-area physician groups, which claimed that they'd conspired to get rid of Medicaid patients in an effort to force the State to pay higher rates. State Attorney General Lisa Madigan had claimed that the Carle Clinic Association and the Christie Clinic had worked together to begin shutting Medicaid patients out of their practice in January 2003. However, the judge ruled that Madigan hadn't proved that the groups had actually colluded, or that their activity had harmed competition in their market. Still, Madigan has permission to amend and refile the case, and her office plans to do so.

To learn more about the case:
- read this Modern Healthcare piece (reg. req.)

Related Articles:
IL suit says private clinics diverted poor to clinics. Report
Illinois doctors fight Medicaid HMO plan. Report
Physicians drop out of new Medicaid plan. Report
Trend: Medicaid programs offer P4P incentives. Report

Minn. critics blast Lilly med monitoring program

Wed, 22 Aug 2007 06:59:55 -0400

Questions continue to dog the medication monitoring program managed by a contractor for drugmaker Eli Lilly, that has been working to cut costs for psychiatric medications for 20 Medicaid programs. Some of the criticism has now surfaced in Minnesota, where foes have blasted the program as inappropriate, given that Lilly not only funds it, but benefits by having the opportunity to remove obstacles to their drugs being prescribed.

Under the program, contractor Comprehensive NeuroScience, reviews use of common psychiatric drugs, and determines whether such usage is outside of standard and effectiveness guidelines. CNS says it often finds patients are taking multiple antipsychotic drugs, which aren't helping them and may even be hurting them. The state sends warning letters to physicians who prescribe outside the guidelines.

Critics, however say this isn't a good idea, given that Lilly manufactures antipsychotic drug Zyprexa, which constituted $28 million of Minnesota's medication costs in 2005. Typically, the Lilly drug isn't on a prior authorization list. However, in Wisconsin, when it added Zyprexa to a prior authorization list, the state was told Lilly was ending its program.

To learn more about these programs:
- read this St. Paul Pioneer-Press piece (reg. req.)

Related Articles:
States seek Lilly help with Zyprexa costs. Report
Lilly accused of promoting off-label Zyprexa use. Report
NIH doctors slam Lilly's marketing tactics. Report
Lilly to pay $500 million to settle Zyprexa diabetes claims. Report

CMS P4P project shows diabetes care savings

Wed, 11 Jul 2007 20:01:37 -0400

While the evidence for cost-savings seems a bit, well, ambiguous, CMS this week is trumpeting the results of the first year of its diabetes care P4P project. CMS has just completed the first year of a three-year demonstration project under which the agency is monitoring diabetes care provided by 10 large medical practices. Diabetes management is being measured by standards drawn from CMS's Doctor's Office Quality project. Under the terms of the demonstration, which was mandated by Congress, CMS is providing financial incentives to practices that save more than 2 percent over projected costs.

Based on these standards, Marshfield Clinic and the University of Michigan Faculty Group Practice, Ann Arbor, earned about $7.3 million, 80 percent of the $9.5 million they're thought to have saved Medicare. Meanwhile, all 10 participating practices met at least seven of 10 clinical benchmarks. Still, it's worth wondering why eight of 10 practices don't seem to have generated significant savings. Let's see what happens when Medicare begins measuring care for congestive heart failure and other conditions over the next few years.

To learn more about the project:
- read this Modern Healthcare article (reg. req.)

Related Articles:
Physicians question CMS P4P effort. Report
Trend: Medicaid programs offer P4P incentives. Report
Positive results for Medicare P4P pilot. Report
Exclusive: How to make P4P work. Interview

CMS seeks rural hospitals for gainsharing program

Sun, 08 Jul 2007 20:01:37 -0400

CMS has begun recruiting rural hospitals for a demonstration project which will examine the impact of gainsharing projects on such hospitals. (Gainsharing refers to programs under which hospitals pay physicians a share of any savings generated by mutual quality and efficiency-improvement efforts.) Under the gainsharing program, the hospitals will be asked to provide their own measures of whether they've managed to improve quality and efficiency of care for Medicare beneficiaries. The rural hospitals will have until Sept. 4 to apply. By the way, don't be surprised if the program description documents include dates from last year; CMS had attempted to roll out a similar program in 2006, but the effort didn't gel, so the agency is trying again.

The new gainsharing program is part of CMS's ongoing efforts to improve care through new incentive payments, the most visible of which is probably its ongoing hospital pay-for-performance initiative.

To learn more about CMS's plans:
- read this Modern Healthcare article (reg. req.)
- read the CMS request for participants (.pdf)

Related Articles:
Physicians question CMS P4P effort. Report
Trend: Medicaid programs offer P4P incentives. Report
Study: Medicare P4P doesn't boost hospital quality. Report
CMS P4P research finds consistency to be key. Report

Psychiatrists getting largest pharma gifts

Tue, 26 Jun 2007 20:01:37 -0400

It looks like psychiatrists are getting the most love from pharmaceutical companies, a relationship which critics say could be behind the increasing use of costly atypical antipsychotic drugs for children.

As states begin to track pharma gifts to doctors, psychiatrists are increasingly coming up as top beneficiaries for pharma payments. In Vermont, for example, pharma payments to psychiatrists more than doubled last year, hitting $45,692 per individual, up from $20,835 in 2005. Data from Minnesota, too, suggests that psychiatrists get the highest compensation from pharmas.

Faced with such numbers, which some say are fueling the staggering rise in antipsychotic drug expenses for Medicaid programs, more states are considering drug maker gift reporting requirements or limits.

To learn more about this trend:
- read this piece in The New York Times (reg. req.)

Related Articles:
NY bill would require pharmas to report MD gifts. Report
NH ban on prescription data use overturned. Report
Doctors weigh in on pros and cons of accepting drug/device freebies. Letters
States tighten screws on pharma marketers. Report

Physicians question CMS P4P effort

Wed, 30 May 2007 20:01:36 -0400

Though it hasn't started yet, physicians are already questioning whether CMS's pay-for-performance program will work over the long term. Physician critics say that many practices won't have the time, resources or staff to begin quality reporting. To get the 1.5 percent bonus, physicians will be asked to report on 74 measures for claims between July 1st and December 31st. To make this happen, it's likely that the practices will have to upgrade their IT infrastructure, a step which can be complex and expensive. That being said, the concerns may be premature. Politics watchers say that the new Democratic leadership in Congress may decide to rewrite the Republican-backed program--or at least rescind the 10 percent Medicare cut planned for 2008. Meanwhile, observers note that funding for the P4P program hasn't been approved yet, leading some to speculate that it won't be implemented after all.

To learn more about the debate:
- read this Modern Healthcare article

Related Articles:
Trend: Medicaid programs offer P4P incentives. Report
Positive results for Medicare P4P pilot. Report
Exclusive: How to make P4P work. Interview