Merrill Experts: HealthCare: healhcare

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Saturday, November 5, 2011

Banner Health Considers Pioneer ACO Contract

Arizona may be the home of the first pioneer ACO, if the state’s Banner Health accepts a contract presented by CMS this week. The largest health system in the state, Banner has a lot to gain from the early adopter ‘pioneer’ program.

In a statement describing massive funding cuts, Banner CEO Peter Fine explained the thought behind the move to ACO.

The traditional model of fee-for-service is gradually giving way to a collaborative model in which reimbursement is shared by hospitals, physicians and other providers based on the health management of defined populations…Doubtless, there will be those who will decry ACOs as a by-product of health-care reform and therefore unworthy of consideration. However, ACOs and similar collaborative models are moving forward whether health-care reform is implemented or not.

For Banner, the only point of concern was timing. “The issue before us now is that of timing. How fast can we bring new models of collaboration into existence?” Fine asked in his statement. As it turns out, it’s a question that many people are asking.

In a white paper available from the Robert Wood Johnson Foundation, authors Berenson RA and Burton RA explain that “…so far, the reception to CMS’ final regulations has been positive, but how many organizations will actually apply to CMS to be ACOs is another question.” The paper attempted to explain CMS’s motives for the ACO Pioneer program, and to establish a prediction on the widespread success of the program. FierceHealthcare summarizes:

How many and how fast will ACOs spread? CMS estimates 50 to 270 ACOs will sign up to participate, generating a net savings of $940 million during the first four years through Shared Savings, according to a recent report by the Urban Institute and the Robert Wood Johnson Foundation…

…According to the report, it's unclear if the Shared Savings Program and the earlier Pioneer ACO model are intended to test the ACO concept for large-scale implementation, to see whether it generates sustainable governmental savings, or to move as many providers as possible to ACOs to curb Medicare spending.

A few years will probably pass before we can come to any definitive conclusions on the program, but the Banner exercise at least demonstrates how much is at stake.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Friday, October 21, 2011

Final Rule Addresses ACO Criticism

At their first announcement, the Centers for Medicare and Medicaid Services’ rules for ACOs caused an uproar. Accountable Care Organizations will reward medical providers that meet certain quality of care requirements, but health professionals found the rules to be needlessly complicated, hard to follow, and unrealistic. CMS responded quickly, committing to rework and improve the rule set.

On October 20^th, the proposed changes, collectively called the final rule, released to public acclaim. CMS Administrator Dr. Donald Berwick told Kaiser Health News, “We have been able to fine tune and improve the rules for a range of stakeholders, providers and patients.” Across the board, health industry officials are praising CMS for the new rule changes, and it seems that these requirements will finally move toward improving the country’s health care.

FierceHealthCare.com put together a table outlining the changes CMS made. We have an excerpt below, or you can view the full table here.

Topic	Proposed rule	Final rule
Transition to risk in Track 1	ACOs offer two tracks. Track 1 would entail two years of one-sided shared savings; then participants would have to transition in third year to a performance-based risk, two-sided model of savings and losses.	ACOs still offer two tracks. Track 1 now removes two-sided risk.
Prospective vs. retrospective	Retrospective assignment based on primary care service use, with prospective identification of benchmark population	Preliminary prospective-assignment with beneficiaries identified quarterly, with final reconciliation after each performance year
Quality measures	65 measures in 5 domains	33 measures in 4 domains
Shared savings	One-sided risk model: Sharing begins at savings of 2 percent Two-sided risk model: Sharing on first dollar	Share on first dollar for all ACOs in both models once min. savings rate is achieved

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Friday, October 14, 2011

Medicare Annual Open Enrollment Begins Early

This year, CMS has announced an early launch for Open Enrollment, which will begin October 15^th, instead of the usual date of November 15^th. The enrollment will end on December 7^th. CMS made this change under hopes that it would improve the enrollment process for Medicare beneficiaries, according to the official press release.

This gives people with Medicare a full seven weeks to compare and make decisions, and ensures that they will have essential plan materials and membership cards in hand on January 1, 2012 when new coverage starts.

In the press release, CMS also made efforts to stress the importance of investigating and exploring plan options.

There'll be a wide range of health and drug plan options available across the country, including Original Medicare. Most people with Medicare can choose a "Part D" plan to help them pay for prescription drugs. And people who have chosen to enroll in a "Part C" Medicare Advantage plan for their basic health care services have the option of staying in that plan, choosing a different plan, or going back to the Original Medicare program. Plans can change from year to year, so these are important choices that should be made with care.

As usual, the organization is making a big push to promote information sources such as 1-800-MEDICARE and http://www.medicare.gov. We saw many efforts being made around this time last year to promote those educational channels, and it is certainly good to see them remaining a large part of CMS’s enrollment initiative.

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Friday, September 23, 2011

News From The 2011 CMS Fall Conference

The CMS Fall Conference this year can be defined with one word: improvements. The conference was designed with a series of breakout sessions, each intended to give CMS experts the ability to hear questions, concerns, and criticisms from those of us in the industry. It wasn’t a one-way conversation, however, as the experts in attendance provided plenty of information and commentary.

As I have already said, CMS made a great effort to stress their initiatives for improving Medicare and Medicaid programs. These efforts will include:

Valuable products
Clear benefits
Accurate communications
Accurate benefits
No tricks at educational events
Regulation-consistent marketing
Secret shopping
A stricter policy on misleading print ads and marketing

On a more positive note, CMS experts were enthusiastic about Part C and Part D programs. They were quick to stress that existing programs were not bad, but that they could do more. These initiatives are all intended to lead to better care, healthier communities, and conformity to ACA law.

The other major point of discussion was the CMS star rating system. A perfect five-star rating can bring many advantages to a plan, including year-round marketing to beneficiaries turning 65. A beneficiary may join or switch to a five-star plan from an MA, MAPD, or PDP plan, barring a few limitations:

Beneficiaries can only join a plan in their area.
They can only enroll in a 2012 plan with a five star rating.
A beneficiary can only use this process one time per year.
If one moves from a plan with drug coverage to a five-star plan that does not have drug coverage, they lose that coverage and cannot return to their previous plan.

CMS warned plans that deliberately structuring themselves to maximize ratings would not be an effective tactic, and that if plans stay focused on overall quality of care, and appropriate care, their star rating will be good.

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Friday, September 16, 2011

The 2011 CMS Fall Conference

It's that time of year again! Halloween decorations are already for sale in malls and grocery stores, the kids are back in school, and the words on everyone's lips are 'Prescription Drug Marketing Compliance."

That last bit may be a bit of an exaggeration, but nevertheless, it is time for the CMS 2011 Medicare Advantage and Prescription Drug Plan Fall Enrollment, Marketing and Compliance Conference. As usual, I, Pamela Argeris, will be attending on behalf of Merrill Corporation. This year's conference promises to be interesting, with plenty of topics that need stronger clarification, combined with the fact that a Presidential election year will soon be upon us:

New Annual Enrollment Period and other related Enrollment Period’s
Medicare Advantage Disenrollment Period/ 5 Star (SEP) Special Enrollment Period
Marketing and Enrollment
Part D IRMAA/ Reinstatement for Good Cause
End of Year Transition and Systems Activity
Quality Improvement Strategy for the Medicare Advantage Program
Changes in the Enrollment Chapters (regulations)

The conference begins on September 20th, and will also be broadcast live on the web, for registered attendees that cannot make it to the conference. There are also planned break-out sessions covering HPMS Training, Retroactive Processing Contractor, and MARx Reports. These sessions will give CMS experts the opportunity to listen to concerns and questions about these systems.

The goal of the Fall conference is to ensure that all sponsors and marketers working within the health and pharmaceutical fields remain up-to-date on the most recent changes to prescription drug marketing compliance.

The CMS Fall Conference is always a great source of information, and Merrill Corporation looks forward to the opportunity to better perfect our health industry services.
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Friday, September 9, 2011

Are Our Hospitals Prepared for Disaster?

It isn't something that many like to bring up, but with the tenth anniversary of 9/11 this weekend, some critics worry that our health facilities haven’t done enough to secure themselves through those ten years. The threat that these critics bring up is an act of bio-terrorism. If there were an outbreak of anthrax, or any other highly contagious disease, as a result of a terrorist attack, would our hospitals be prepared to handle it?

A report issued Sept. 1 by Trust for America's Health and the Robert Wood Johnson Foundation shows that significant public health improvements were made following the 2001 events.

Such improvements include developing clear emergency response plans, bolstering laboratory staffing and bio-testing capabilities, and implementing more effective disease surveillance systems in state health departments.

But during the past 10 years, the report says these efforts have been losing effectiveness, due largely to public health budget cuts. The cuts are leaving many departments across the country with too few staff members to adequately implement the measures.

This American Medical News article stresses that public health employees would be the first to recognize the signs of a large-scale bioterrorist attack, and recent budget cuts have drastically reduced their numbers. Further, critics point out that our health defenses have become too complacent, and that we will not be capable of defending a terrorist attack until after the attack has occurred.

A similar NJ.com column does mention that, after 9/11, many emergency procedures were put in place, with the intention of preparing hospitals for any disaster. However, low staffing and funding mean that very few hospitals would actually be able to follow through with their plans, should anything occur.

For the sake of future safety, it is clear that something needs to change, but many experts are left questioning what that change could actually be.

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Friday, September 2, 2011

Irene Leaves A Paper Trail

During natural disasters, the preservation of human life takes precedence over anything else. When it comes to health facilities, that can often mean the relocation or evacuation of patients and staff. In the case of the recent Hurricane Irene, it also meant that many facilities were suddenly faced with the massive logistical and compliance problems of moving hundreds of patients out of hospitals and nursing homes.

Now that the threat has passed, many hospitals are left with a paperwork nightmare that could take days to sort through.

Many questions have arisen. What is the Medicare and Medicaid reimbursement policy with respect to the transfer of patients between institutions? If a federal disaster area is declared, do the feds pick up the tab? How will private insurers pay for the costs incurred?

Crain’s New York Business asked CEO of the New York State Health Facilities Association, Richard Herrick, for his opinion. “The question is, who pays for what? Who bills for the services and costs incurred?” It is certainly a perplexing problem.

For many of the states affected, nothing on this scale has ever occurred, and contingency plans to handle the crisis were not in place. It is unreasonable to expect every facility to prepare for every possible disaster, but until federal agencies are willing to provide answers, many health facilities will be left to work things out on their own.

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Friday, August 26, 2011

Large Data Breach Causes Data Integrity Questions

A California firm, Southern California Medical-Legal Consultants, has been the most recent facility to make headlines with a massive data breach. The breach, which released the medical records, social security information, and personal details of 300,000 patients, was caused by poor handling and a lack of knowledge. Joel Hecht, owner of the consulting firm, believed he was storing the data on a private website. In reality, it was being placed into a public server, without even the most basic of security measures.

The personal data was discovered by Aaron Titus, a researcher with Identity Finder who then alerted Hecht's firm and The Associated Press. He found it through Internet searches, a common tactic for finding private information posted on unsecured sites.

The data was "available to anyone in the world with half a brain and access to Google," Titus says.

Titus says Hecht's company failed to use two basic techniques that could have protected the data -- requiring a password and instructing search engines not to index the pages. He called the breach "likely a case of felony stupidity."

The breach, which was discovered and locked down last week, has led many to question the upcoming 2014 regulation requiring all medical data to be stored online. While it is obvious that this breach was caused more by ignorance than by hidden insecurities, the argument has been made that other under-trained facilities are likely to follow suit. The Associated Press theorizes that the underlying cause of this breach is the fact that the medical records were so far removed from their original source. While hospitals are usually well-equipped for this kind of data, the AP says, “The further away from the health care provider the records get, the flimsier the enforcement mechanisms for ensuring the data are protected.”

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Friday, August 19, 2011

Arguments Continue On ACA Constitutionality

Image from thefbomb.org

The Georgia Appeals Court becomes the second appellate to join the never-ending debate swirling around Obama’s Affordable Care Act. According to the court, the individual mandate – the portion of the legislation requiring all citizens to purchase health care – is unconstitutional, and “an unprecedented exercise of congressional power.” This follows a similar January ruling by US District Judge Roger Vinson, and an opposing ruling from the Ohio Appeals Court in June.

The Georgia ruling supports most of what Florida’s Judge Vinson declared in January, with a significant provision. While Vinson felt that the entire legislation was a cohesive, unchangeable unit, the Georgia court believes that the offending individual mandate can be removed from the ACA, while allowing the rest of the Act to function as law.

As pointed out in a recent news article on Medscape.com, continuing dissension will likely force the Supreme Court to re-investigate the controversy, and to pass down an official decision. Until that happens, smaller courts will likely continue the debate.

The issue of the constitutionality of the Affordable Care Act is also before a US Appellate Court in Richmond, Virginia, which is weighing appeals of two lower-court decisions in that state. A federal district judge in Lynchburg, Virginia upheld the individual mandate, whereas another in Richmond, Virginia, struck it down. A ruling from this third appellate court is expected soon.

Whatever Virginia’s decision is, we will probably not be seeing the end of this discussion any time soon.

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Friday, August 12, 2011

Mobile Tech Replaces Pagers, Worries HIPAA

The cliche image of an off-duty doctor receiving an emergency page is a thing of the past. These days, many docs receive up-to-the-minute patient updates through text messages, sent unencrypted from the hospital. Obviously, there are a few problems here waiting to happen.

According to Becker's Hospital Review,

The e-mails are entered by the hospital employee, converted into a text message and sent to the physician's cellular phone. Physicians frequently request that more patient data is included in the message, such as the patient's name and room number, so the physician can look up the chart prior to returning the call. This system is frequently not encrypted, however, because of the extra expense to the hospital.

This revelation sent red flags up for HIPAA. Imagine their horror when it was learned that some hospital employees simply send these texts from personal cell phones, rather than through monitored hospital email systems.

The problems begin with the fact that this kind of communication, while expedient, is not protected by any level of security. This puts these kinds of communications in violation of the Security Standards, which "require Covered Entities to (1) ensure the confidentially, integrity and availability of the information; (2) protect against any reasonably anticipated threats or risks to the security or integrity of the information; and (3) protect against unauthorized uses or disclosures of the information." And this is just the start of the laundry list of violations.

The very fact that these communications take place on "high risk" items like cell phones and tablet computers furthers the issue. The National Institute of Standards and Technology increases the risk level for items likely to be lost, stolen, or compromised, and cell phones are right at the top of that list.

Is this just one more case of consumer technology surpassing medical technology? Perhaps, but it is still a significant issue that requires a little more thought.

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Thursday, August 4, 2011

CMS Announces Quality of Care Initiatives

The Centers for Medicare and Medicaid Services has had a busy seven days, releasing information on four new initiatives since July 29^th. Three of these focus on accuracy and payment changes for Medicare in fiscal year 2012, and the last describes policy changes for inpatient rehabilitation facilities.

CMS ANNOUNCES MORE ACCURATE FY 2012 PAYMENTS FOR MEDICARE SKILLED NURSING FACILITIES

A spike in payment levels inspired this policy, which will align Medicare payments with costs, reducing Medicare skilled nursing facility Prospective Payment System payments by $3.87 billion. This reduction is a drop of 11.1% from FY 2011. In the press release, CMS Administrator Donald M. Berwick, M.D. says, “CMS is committed to providing high quality care to those in skilled nursing facilities and to pay those facilities properly for that care…The adjustments to the payment rates for next year reflect that policy.”

The 2011 spike was caused by a miscalculation when CMS attempted to restrict damage caused by the Resource Utilization Groups Version 4 (RUG-IV) classification system.

FINAL WAGE INDEX CHANGES FOR MEDICARE HOSPICES INCREASE FY 2012 PAYMENTS BY 2.5%

In an effort to improve the quality of care in hospices, CMS is increasing payments to hospices treating Medicare patients by 2.5%. The increase will come at the cost of required quality of care reporting for those patients. In further detail, the release explains that, “CMS calculates each hospice’s aggregate cap by multiplying the number of patients served by the hospice in a cap year by a cap amount. Medicare payments made to a hospice during the cap year that exceed the hospice’s aggregate cap must be refunded to Medicare.”

MEDICARE PAYMENT RULE PROMOTES IMPROVED INPATIENT CARE

CMS has also approved a similar rule, geared to improve inpatient care in general acute-care and long-term-care hospitals. “The final rule continues a payment approach that encourages hospitals to adopt practices that reduce errors and prevent patients from acquiring new illnesses or injuries during a hospital stay,” said CMS Administrator Donald M. Berwick, M.D. “This approach is part of a comprehensive strategy being implemented across Medicare’s payment systems that is intended to reduce overall costs by improving how care is delivered.”

This rule meshes with an ACA requirement that reduces Medicare pay-outs to hospitals with high readmission levels for certain conditions.

CMS IMPLEMENTS PAYMENT, POLICY CHANGES FOR INPATIENT REHABILITATION FACILITIES

Another CMS ruling is set to increase “IRF payment rates under the IRF Prospective Payment System (PPS) by 2.2 percent and establishes a new quality reporting system authorized by the Affordable Care Act.” The rule will take effect in FY 2012, and will provide further motivation for hospitals and other health facilities to improve inpatient care practices.

In addition, the final rule will update the case-mix group relative weights using FY 2010 IRF claims and FY 2009 IRF cost report data, freeze the facility-level adjustment factors for FY 2012 at FY 2011 levels for one additional year while the agency explores ways to improve upon the accuracy and consistency of the current methodology used to calculate the facility-level adjustment factors, and allow IRF and inpatient psychiatric facility units to expand in the middle of a cost reporting period, rather than restricting such expansions to the start of a cost reporting period.

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Thursday, July 28, 2011

The Clock is Ticking on the Debt Ceiling

It is time to get serious in Washington. Many people throughout the United States are waiting for a deal or compromise to be reached on the debt ceiling. The most sensitive population among those is the elderly that Medicare services. It is unfair for elected officials to rely on their votes to be placed into office, and then fail them when the going gets tough, so to speak. Everyone needs to adjust their thinking and keep in mind that people's parents or grandparents are sitting at home watching this calamity unfold in the media.

Many seniors have voiced a fear of losing their Social Security - which is their only source of income in many cases - as well as their Medicare benefits. As we know, a means test has been proportioned into Medicare via the Affordable Care Act. This test increases the premiums of the well off in Medicare. Invoking any additional increase to this means test at this point is uncalled for.

The Washington crowd needs to be open minded, roll up their sleeves, and serve up a solution that will work for all, and especially for our senior citizens who are fearful of losing at every turn.

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Thursday, July 21, 2011

HIPAA Regulations and New Technology: HIPAA, HITECH, and Electronic Compliance

HIPAA and HITECH violations are on the rise, and as more and more technology pushes medical records into the realm of EHRs and cloud storage, things will not likely improve. Why exactly is this happening? Sarah E. Swank has a few ideas (free registration required to view article):

In the old paper world before HIPAA, people often guarded patient medical records with good old-fashioned common sense…Our HIPAA policies are stale and our workforce members receive training often created with a focus on paper medical records. In addition, the technology has not caught up with expectations of electronic health record systems to audit access in real time.

It has been said, time and time again, that HIPAA is behind the times when it comes to new forms of communication. This has been most evident in the realms of social media, where companies and facilities are forced to choose between posting what they think is OK while hoping to dodge the compliance axe, or ignoring the platform altogether. So what can medical organizations do to keep their information secure while HIPAA catches up?

Swank lists seven strategies in her article on lexology.com;

Conduct Regular and Routine Audits
Review Incident Reporting Procedures
Conduct Timely and Complete Investigations
Review and Update Policies and Procedures
Reevaluate Training
Rethink Discipline Determination
Mitigation

What these strategies boil down to is essentially this: Change, Vigilance, and Consistency. Organizations must step up to develop methods of tracking and protecting data in an electronic environment, which can be a complex and daunting task for a group used to handling paper records. HIPAA may have been old hat a few years ago, but we are all back in unfamiliar territory, and it is necessary to give your compliance strategies a second look.

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Friday, July 8, 2011

HIPAA Regulations and New Technology: Where Does Mobile Fit In?

There are plenty of obvious compliance issues presented by healthcare’s move toward mobile technology. This recent article from Mobi Health News points out one of the less blatant struggles that any health facilities face.

The [HIPAA] Privacy, Security, and Breach Notification Rules can be a daunting challenge. Sometimes, the biggest question facing mobile application developers is not how to comply with (or make sure users are complying with) HIPAA, but rather whether HIPAA even applies.

It seems that the twisting and complex labyrinth that is HIPAA compliance has more backdoors, pitfalls, and secret exits than anyone could have predicted. The good news is that many mobile software efforts may not even fall under HIPAA’s compliance jurisdiction. The bad news is that it can be very tricky figuring out what side of that line you fall on.

In the article, Adam Greene explains that, “The HIPAA Rules only apply to HIPAA ‘covered entities’ and their ‘business associates.’ They do not apply to health care consumers or to other types of entities.” This means that the people that have access to the software are the first determinate of whether or not HIPAA compliance applies to your software. He explains further that:

A mobile application developer will need to analyze whether the software will be used by a covered entity, such as physician, hospital, or health plan, and whether it will include any protected health information: individually identifiable information about health, health care services, or payment for health care services. An application that assists a physician with following up with patients would need to be designed to allow the physician to comply with HIPAA. Likewise, a mobile application for use by health plan employees to obtain an individual’s enrollment information remotely would need to be designed in accordance with HIPAA.

The take-away here is that health facilities can distribute software that monitors medication schedules, important general health information, and other information, so long as it is not directly linked to any “covered entities.” Obviously, this is a complicated matter that should not be tackled without a lot of thought and research, but it is good to know that – on the surface, anyway – HIPAA is not preventing health facilities from helping the public get the best medical information possible.

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Thursday, June 30, 2011

Middle Class on Medicaid?

There has been no shortage of controversy surrounding the Obama Administration’s Affordable Care Act. Recent debates have brought up the 10 million additional children and 20 million additional adults Medicaid will be picking up. We’ve also seen dialogue on the 138% poverty level, and access gained by childless adults. Now, a new unforeseen problem in the legislation’s wording will allow early retirees to jump on the Medicaid bandwagon.

Two years from now, many people will begin early retirement, leaving the workforce at 62. During the three years between their retirement and joining Medicare at 65, social security payments will not count toward their annual income mix. This will allow up to 3 million early retirees to gain access to Medicaid in 2014.

Many of the legislators on Capitol Hill are concerned that overloaded state Medicaid programs will further crumble under this flaw. Presently, the administration has addressed the problem, and is seeking a solution, but until something is presented, this is simply another hiccup adding fuel to the anti-ACA flames.

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Thursday, June 23, 2011

HIPAA & EHR Security -- Can the Answer Be Found in the Cloud?

On a public website, the Department of Health and Human Services maintains an infamous list known as the “wall of shame.” The site publishes the names of facilities responsible for HIPAA violations affecting 500 or more people. But do we truly understand how the violations occur? With so many recent news stories about online security and super-hacker group LulzSec, it is easy to blame digital recording. However, after a closer review of the HHS website information, that simply is not the case.

Most often, violations occur due to physical theft and loss. The statistics provided in a recent Software Advice article state that only 6% of the violations are attributed to hacker activities. Of the remaining incidents, 61% are linked to physical theft and loss. Why is there such a difference between public view and reality? Part of it is the media; a story about criminal elements breaking in to secure servers is more interesting than one in which an otherwise skilled employee misplaces a disc. Another part of it is fear. When the public hears about hackers gathering millions of credit card numbers overnight, they assume that all online data is up for grabs.

Whatever the reason, the facts are clear. The vast majority of HIPAA violations and data loss are due to the mishandling of physical files or equipment. With that in mind, EHR security must continue to evolve and work closely in conjunction with newer technologies that show signs of stronger security for our most sensitive personal information.

Cloud technology could allow these medical records to exist in a purely electronic form. Online banking has been commonplace for years, with hardly a second thought and as Michael Koplov, author of this Software Advice article, succinctly points out, “Just a hunch, but I bet more hackers want my credit card information than my HDL/LDL ratio.” In a comment to Merrill Corp, he goes on to say, “I analyzed this data and found that the HHS has no record of cloud-based EHRs being implicated in these large-scale security breaches.”

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Thursday, June 16, 2011

Microscopic Science, Big Results

Scientists in the health field have been putting a lot of effort and time into researching the genetics of common health problems, and that energy is starting to pay off. Today, some of the most debilitating common conditions are being explained at a microscopic level. These finds may seem inconsequential now, but within a few short years, the fringes of modern medicine may use this research for cures.

Migraines -- severe headaches that come bundled with hazy vision, nausea, and hyper-sensitivity -- have been traced down to three individual genes. Of those three, one occurs exclusively in women, explaining why women have always been more prone to the debilitating headaches. If scientists can target these genes and shut them off, severe headaches may be a thing of the past.

http://1.usa.gov/k7tPxr

A more universal issue is being solved thanks to breakthroughs made in chromosome research. DNA strands called telomeres cap the ends of chromosomes in living cells. When these caps wear away, due often to physical or mental stress, the cell dies. Faster cell death essentially means faster aging. Though typically linked to those that suffered childhood abuse, any extreme stress can shorten telomeres. Experts recommend the usual dose of increased activity and exercise, as even the most abused individuals were able to divert stress and increase telomere length through activity and exercise.

As science delves deeper and deeper into genetic research, we may see the genetic switches responsible for many causes of human suffering. The things we are accomplishing today were considered fringe medicine a decade ago, and the things we cannot dream of doing today may be commonplace in the near future.

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Friday, April 22, 2011

CMS 2011 Spring Conference Wrap-Up

The CMS 2011 Spring Conference has officially wrapped up, and once again a large amount of information came directly from CMS on the state of the market, what their expectations are and what plans need to do to succeed in the new world of healthcare. As is customary, Jonathan Blum, Deputy Administrator and Director of CMS, had the keynote speech.

Mr. Blum spoke about the 2012 CMS Priorities for the Medicare Part C and Part D Programs and beyond. CMS’s focus is on the following three items:

Consistency
Quality Improvement
Continued focus on Compliance

Consistency
CMS’s view of consistency means policy consistency. Simplifying programs, benefits and plan choices for beneficiaries; making navigation of the Part C & D programs easier for beneficiaries overall. CMS has a great deal of policy to implement via the Affordable Care Act, so they are seeking to allow systems and plans time to catch up by holding steady with policy issuance.

Quality Improvement

The 5 Star Bonus Payment System signals that CMS cares about quality, improving scores and rewarding good plans. Ratings are provided as a consumer tool and payment mechanism. As such, in 2012, 5 Star Plans will be allowed to market enrollment year round; while plans with 2 Stars consistently for 3 or more years will not be allowed to offer products to beneficiaries. Overall growth of 7% has been recognized in Medicare Advantage for 2011; this growth is even faster for 4 Star and higher plans. Plans are focused on improving ratings so beneficiaries gravitate to their plans.

Continued focus on ComplianceCMS has a heightened focus on compliance, audits, and performance. This can be seen in the way 2010 audits were conducted. Several overall trends appeared during the audits that all plans should take note of. The areas consisted of Part D Formularies, Coverage Determinations, Grievances, and Enrollment & Disenrollment Processes.

In addition, Mr. Blum stated that plans should understand their business better than CMS. They should see and identify trends and issues before CMS. Understanding why their beneficiaries are calling is critical to correcting issues immediately. The top area of concern noted in the audit findings centered on oversight of a plan’s Pharmacy Benefits Manager (PBM). While CMS understands this is a delegated role the plan must remember they are ultimately responsible to the member and CMS to ensure their enrollees receive their medications. The oversight of the PBM must be conducted on a daily basis to avoid issues and ensure beneficiaries receive their medications at point of sale. Special attention should be paid to protected classes and transition of medications; multiple problems were cited in these areas. Proper and timely processing of coverage determinations and grievances is critical to remain in compliance. Also, plans must ensure their enrollment and disenrollment processes are working fluently. Take the time to build internal controls and workflow processes to avoid issues later down the road.

Overall, CMS is focusing on becoming more forthright. Compliance is of utmost importance. Better Compliance + Better Performance = Higher Plan Reimbursement. As the Medicare program continues to grow and expand the plans that do well will receive more members.

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Friday, April 8, 2011

Census Says Life Expectancy is Up, But Why?

Recent census data shows that the US average life expectancy has increased to a record-breaking 78 years. The immediate thought that most people have when presented with this information is that improving medical technology and increased health is leading to longer lives. To some extent, that is true. While there is a clear correlation between life expectancy and medical advances, this number does not really mean that the average person is living a longer life.

In reality, average life expectancy is determined almost entirely by infant mortality rate. In this most recent report, the CDC listed “a record low of 6.42 deaths per 1,000 live births, a drop of nearly 3% from 2008.” This number was 100 out of 1000 as recently as 1920, creating a statistic that implies that most people are living up to twenty years longer than they have in the past. This is simply not true.

Death rates are likely to continue dropping over the next decades as medical advances remove the threat of curable disease. The increasing unpopularity of smoking adds to this number as well. This ratio of infant-mortality and death rate will continue to influence life expectancy, but we do not need to start worrying about running out of retirement homes any time soon.

Monday, August 23, 2010

Healthcare Facts vs. Healthcare Opinions: Which is winning?

Knowledge is power, right? How much do you know about the new healthcare law? Have you heard that it will cut Medicare benefits for seniors, decrease payments to doctors and ration healthcare?

You may have, but it’s not true. In a recent poll, high percentages of Americans expressed that they believe the above three actions to be true. Even half of those surveyed believed in the death panel myth, the idea that these panels could make end-of-life decisions.

While some would say that these poll results bring to light the influence some members of the media have in presenting opinions as facts, the larger point is that this current method of information dissemination could lead to people not being able to take full advantage of benefits that exist and could help them.

As marketing communications experts, and in an attempt to aid both the general public and those healthcare organizations that want to provide a true list, we would like to do our part in making clear what new benefits exist. More information on these facts can be found on the Department of Health and Human Services website.

Young adults who lack coverage can remain on their parents’ plan until they turn 26.
Approximately four million small businesses are eligible for tax credits of up to 35 percent off their health insurance costs.
People can get tests such as mammograms or colonoscopies without having to pay a share of the cost.
People who have pre-existing conditions or are uninsured for at least six months can get high-risk coverage through a state or federal high-risk pool.

We know that an issue this big will never be apolitical (especially in an election year), nor should it necessarily be in a free society. However, as the September triggers approach, it will be to the benefit of healthcare organizations that have knowledge in this arena to lead (not sway) the public through the complexity of this issue.