healthsignals new york

Well, if you can't get it right the first time ...

From the CMS OIG, without comment:

This inspection found that 20 percent of sequences of three or more consecutive Medicare inpatient stays were associated with quality of care problems and or unnecessary fragmentation of healthcare services across multiple inpatient stays.

Quality of care problems were defined as patient care that did not meet professionally recognized standards, medical errors, or accidents. Unnecessary fragmentation of services involved cases in which care provided across sequences of multiple inpatient stays may have been necessary and appropriate but should have been consolidated to fewer stays.  Medicare paid an estimated $267 million for these sequences of stays in fiscal year 2002. This inspection also found that 10 percent of individual stays within consecutive inpatient stay sequences were associated with poor quality of patient care. OIG recommended that CMS direct quality improvement organizations and fiscal intermediaries, as appropriate, to monitor the quality, medical necessity, and appropriateness of inpatient services provided within this types of sequences of consecutive Medicare inpatient stays that we included in our review. 

CMS concurred with OIG's case findings but stated that periodic reviews are sequences of consecutive inpatient stays are not warranted.

Here's the full report (PDF).

Another form of "clawback"?

A colleague with great expertise in income support policies and programs told me yesterday that he had just learned that the US Department of Agriculture, which administers the Food Stamps program, will be counting the Medicare Part D pharmaceutical benefit as income to low income Food Stamps beneficiaries. More "income" means lower benefits.

He's researching it and I will too, but he's usually got this stuff nailed.

What's it mean? The more Medicare pays for drugs, the less Food Stamps you get. Worse, if true, the Food Stamp benefit will change monthly based on what Medicare spent for drugs in a prior period. Mind you, because of the way Food Stamps work, there may still be a positive net benefit. But this will be an administrative morass as well as making the lives of beneficiaries more uncertain.

The Administration giveth and the Administration taketh away.

Where's the "crisis"?

I've avoided posting on the recent release of the Social Security and Medicare Trustee's annual reports. It's the wonky part of me that feels compelled to actually read them before doing so. Here are the summaries and here's where you can get the reports.

But if you're interested in the short version, just look at the graphic in this Washington Post story by Jonathan Weisman.

What will catch your eye first is the longer range projections. But note how soon Medicare overtakes Social Security, accounting for a larger portion of gross domestic product (GDP). It's less than twenty years.

Note also the long range projection of Medicare costs as a percent of GDP (13.7). We talked last year at this time about projections and forecasting that far into the future is a dicey thing. But spending 13.7 percent of the nation's economy on Medicare? That's quite a chunk. Even if one assumes that the proportion of GDP spent on the rest of healthcare remained constant (a highly dubious proposition), one-quarter of our economy would be spent in healthcare.

There's nothing intrinsically bad about any particular percentage of GDP being spent on healthcare generally or Medicare in particular. And we should assume that if and as we become more prosperous, we will spend more. However, there is a threshold or a range of thresholds at which the rest of the economy pushes back hard. That's going to happen long before these projects come to pass. Indeed, it's already begun.

Scratched by the claw(back)

What a surprise, right? The "Medicare Modernization Act," that gives us the new pharmaceutical benefit may cost the states money.

The simple version:

• Lots of Medicaid clients are also Medicare clients.
• Lots of these "dually eligible" folks are sick and use lots of pharmaceuticals.
• This is especially so for those in nursing homes
• So when the Federal government created the new pharmaceutical benefit, it recognized that it would be paying for drugs that were previously being paid for under Medicaid. That would simply have shifted the cost from states to the Federal government
• To offset that effect, the new law includes a provision (tenderly called the "clawback") that establishes a formula by which the states pay the Federal government

Turns out the formula works against some states generating a net cost. It may even create the biggest disadvantage for states that had created the most cost-effective programs.

There may even be Constitutional issues regarding the Federal government's requiring states to pay for a Federal benefit in which they do not otherwise participate.

Maybe the Governors could take some lessons from county officials in New York.

Medicare and Social Security

Though what we talk about here is healthcare and health policy, I've had this nagging feeling the past couple of weeks that we should be talking about Social Security too. Now I know why. Thanks to Kevin Drum of Washington Monthly for putting it in perspective. 

Talk about the need for quality improvement

Ummm. This is reassuring.

The GAO did a quality review (PDF) (abstract-only) of Medicare's toll-free telephone line about new prescription drug benefits and drug discount cards. Accurate answers were provided less than two-thirds of the time. Twenty-nine percent received inaccurate answers. Ten percent got no answers.

And just think: In a little over a year, the program will be even more complex.

The Times also reported that Medicare did even worse on billing questions:

Medicare provided even less accurate information to doctors who inquired about the proper way to bill for treating Medicare patients.

In response to 300 test calls, the accountability office said, customer service representatives gave correct and complete responses to only 4 percent of the billing questions. About 54 percent of the answers were simply wrong, and 42 percent were incomplete or partly correct, it said.

Now what happens when a physician follows the advice and subsequently gets audited?

Medicare chronic illness management

CMS has announced the awards for programs to improve care of Medicare beneficiaries with chronic illnesses. Here's their press release.

Phase I pilot programs will be operated by:

• Aetna Health Management in Chicago
• American Healthways Inc. in the District of Columbia and Maryland
• CIGNA HealthCare in Georgia
• Health Dialog Services Corporation in Pennsylvania
• Humana, Inc. in Central Florida
• LifeMasters Supported SelfCare, Inc. in Oklahoma
• McKesson Health Solutions in Mississippi
• Visiting Nurse Service of New York in partnership with United HealthCare Services, Inc.- Evercare (more here) in Queens and Brooklyn in New York City 
• XLHealth in Tennessee

Here's Matthew Holt's provocative take on it all: "Medicare DSM demos are awarded, but not to providers." He doesn't mention the one New York project and I don't know anything about it. Guess I'll have to find out. Here's my take from a few months back on a question Matthew raises.

Medicare RX and nursing home patients

Not everyone's ready to make the pharmaceutical plan choices required in Medicare Modernization Act, particularly nursing home residents. Less than 13 months to go and ...

Federal and state officials, pharmacists and nursing home directors said they had no idea how these patients would obtain their medicines under the new program, which begins in January 2006.

"The way it's supposed to work under the new law is totally confusing," said Joan E. DaVanzo, vice president of the Lewin Group, which recently received a federal contract to study pharmacy services in nursing homes. "The mandates of the law run contrary to the practice of the industry. The law presumes that Medicare beneficiaries are sophisticated elderly people living in the community and using retail drugstores." In fact, more than one-third of nursing home residents have Alzheimer's disease or another form of dementia, so they cannot easily compare the costs and benefits of different plans. At least one-fifth of nursing home patients have difficulty swallowing. Many receive medications and nutrition through feeding tubes, so they require drugs in a liquid or crushable form.

And best of all ...

"We don't have a clue how the system is supposed to work under the new law," said Laurence F. Lane, vice president of Genesis HealthCare, which operates 192 nursing homes in 12 states. "We don't know what will happen on Jan. 1, 2006."

"If nursing homes have to deal with multiple formularies from multiple prescription drug plans, that will result in chaos and an increased potential for medication errors," said Thomas R. Clark, policy director for the American Society of Consultant Pharmacists, whose 7,000 members specialize in drug care for the elderly.

Reassuring huh?

CBO on disease management ... the jury's out on their primary concern

The Congressional Budget Office has a new report out on Disease Management programs.

According to CBO’s analysis, there is insufficient evidence to conclude that disease management programs can generally reduce overall health spending. It is important to note that such programs could be worthwhile even if they did not reduce costs, but CBO’s analysis focused on the question of whether those programs could pay for themselves. The proposition that decreased use of acute care services might offset the costs of the screening, monitoring, and educational services in disease management programs is clearly appealing, but, unfortunately, much of the literature on those programs does not directly address health care costs. Instead, the focus is often on the processes of care or on intermediate measures of health, from which an overall impact on spending cannot reasonably be inferred. The few studies that report cost savings do so for controlled settings and generally fail to account for all health care costs, including the cost of the intervention itself. Furthermore, if disease management programs were applied to broader populations, the reported savings might not be attainable, and the programs could even raise costs. So while a few studies indicate that disease management programs could be designed to reduce overall health costs for select groups of patients (at least in the short term), little research directly addresses the issues that would arise in applying disease management to the older and sicker Medicare population.

They go on to say that the jury is still out and they will

...continue to monitor this research as new information becomes available—in particular, the results of disease management demonstration projects now being developed by the Centers for Medicare and Medicaid Services.

Things are far enough along so that we should be evaluating Disease Management programs rigorously. That said, we also should be evaluating rigorously care of patients that are unmanaged. The status quo, fee-for-service system is hardly a worthy benchmark for qualty, efficiency and effectiveness.

Medicare RX cards' slow expansion

From Daniel B. Moskowitz by way of Medscape ...

The response of seniors to the Medicare-endorsed private prescription drug discount cards so far has been less than enthusiastic. When the card program went into operation June 1, just under 2.9 million seniors had cards in hand—far below the 7.3 million that the Bush Administration had suggested would be enrolled.

"It's been a very slow uptake," said Tim Dickman, chief executive officer, Prime Therapeutics. AARP, for example, sent out 26,000 enrollment kits to members and had only 400 sign-ups by June 1 ...

There's even less support for the discount cards than the raw numbers suggest. Only about 500,000 of the 2.9 million actually signed up for a card. The rest were issued cards automatically by the Medicare managed care plans in which they were already enrolled.

The Bush Administration seems to have abandoned its 7.3 million cardholder projection. Mark McClellan, head of the Centers for Medicare & Medicaid Services (CMS), now talks in terms of "hundreds of thousands" more enrollees. To reach that goal, CMS is looking to follow the lead of private Medicare HMOs and rely on automatic enrollment to boost the numbers. In a June 8 testimony, McClellan told the Senate Finance Committee that he expects to get 400,000 more cardholders through automatic enrollment of seniors already participating in state drug-purchasing assistance programs in Maine, Massachusetts, Connecticut, New York, New Jersey, Pennsylvania, and Michigan.

"Less than enthusiastic"? (2/9/7.3) "Very slow uptake"? (400/23,000)

Wow, what terrible results! If this were a private sector rollout, it would be heads that were rolling. Are these the folks who want to run government like a business? Or is this just how they run businesses?