4 challenges facing government healthcare programs

The Office of Inspector General yesterday released its annual report of the top 10 management and performance challenges facing the U.S. Department of Health & Human Services. The report documented the vulnerabilities and emerging issues for government healthcare programs, followed by OIG's assessment of "what needs to be done" to overcome them. Here's a summary of four main challenges for HHS:

1. Health insurance exchange oversight

HHS must enhance HealthCare.gov for overall functionality of the federal health insurance enrollment website. This means guaranteeing HealthCare.gov verifies information; accurately determines eligibility, tax credits and subsidies; and transmits correct data. The department also must ensure marketplace contractors deliver products and services on schedule and within budget.The report also notes HHS must implement systems to pay insurers accurately before issuing premium credits, cost-sharing subsidies and premium stabilization payments, as well as data security and eligibility safeguards that protect consumers' information while integrating data from many feeds.              

2. Value-based payment transition

Since there's a stake in the heart of fee-for-service payment models based on the thinking that they waste money and hurt quality, HHS is transitioning to value-based reimbursement in Medicare and Medicaid. A major challenge of this move is linking quality, performance and payment effectively. HHS must get value-based payment structures and rates right by designing incentives that align with cost and quality goals without producing unwanted outcomes, according to the OIG. The department also must focus on data integrity for accurate, reliable claims information.

3. Medicaid expansion integrity

OIG called on the Centers for Medicare & Medicaid Services to "develop robust oversight" for Medicaid expansion. This includes keeping an eye on state compliance with eligibility requirements. CMS also must heighten efforts to fight fraud and eliminate excessive payments to public providers. So far, about half of U.S. states have declined to expand Medicaid eligibility as part of the Affordable Care Act--a decision that will cost them and their providers tens of billions of dollars over the next several years.

4. Improper payment, fraud prevention

Improper Medicare Advantage payments cost taxpayers billions of dollars, OIG noted. To stop this hemorrhage, CMS must get payers to implement effective anti-fraud programs and report fraud for possible law enforcement referral. And CMS should develop a centralized bank of Medicare Advantage data to enhance big-picture program oversight. Moreover, CMS must ensure Medicare Advantage organizations submit accurate beneficiary diagnoses for setting risk adjustment payments and recover overpayments following inaccurate plan data reporting. These Medicare Advantage overpayments totaled more than $5.1 billion between 2010 and 2012.

For more:
- read the OIG report

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