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April 19, 2010

Washington Health Policy Week in Review Archive a3e5d9b6-2db2-4c33-a975-297413a9cb0a

Newsletter Article


CMS Needs to Step Up Oversight of Nation's Worst Nursing Homes, GAO Says

By Jane Norman, CQ HealthBeat Associate Editor

April 16, 2010 -- A Government Accountability Office report to be released on Monday says the nation's worst nursing homes are in some cases improving, but the government could do a better job in identifying them and tracking their deficiencies.

The report found that some homes improved and graduated from a special program designed to pinpoint the worst facilities — even though they had not been surveyed as often as required or subject to the tougher enforcement required by the government for the most poorly performing homes. Decisions to publicize the names of the worst homes and make sure owners and boards of directors know about the label "have given homes additional incentives to improve their performance," said the report.

In addition, nursing homes that graduated from the special program because they improved often failed to sustain that improvement, the GAO said.

The results would be better if the Centers for Medicare and Medicaid Services (CMS) followed a GAO recommendation to compile a list of the worst homes nationally rather than on a state-by-state basis, the GAO said. In addition, CMS guidance to states is "vague" and interpreted in different ways by different regional and state offices, the report said. Homes with similar problems with compliance receive different fines, for example.

In their reply, CMS officials agreed with five of six recommendations for improvement made by GAO and said they would consider the other one — charging the nursing homes for additional surveys required for the worst homes.

"While we are encouraged by data indicating that CMS' Special Focus Facility initiative is producing positive and enduring results, we remain concerned by those nursing homes in the program that do relapse into a pattern of serious deficiencies, and by the length of time it is taking for some nursing homes to evidence improvement," said CMS. "During any period of relapse, nursing home residents suffer."

The report on the Special Focus Facility Program, or SFF, was requested by senators Herb Kohl of Wisconsin, a Democrat, and Charles E. Grassley of Iowa, a Republican.

Some 1.4 million elderly and disabled Americans live in nursing homes and the SFF is a list of the poorest-performing homes in each state — that, for example, have been cited repeatedly for serious deficiencies such as residents with preventable pressure sores that harmed them or put them at risk of death.

State agencies are responsible for conducting inspections and investigations of violations in nursing homes, under contract with CMS. Earlier reports by the GAO found some homes to be noncompliant over a long period of time, and 12 years ago the government developed the SFF program as a way of monitoring the two worst homes in every state. Such homes are looked at twice as often and more subject to enforcement.

The program since has been expanded to 136 homes nationwide, or up to six per state, which would take in less than 1 percent of the nation's 16,000 nursing homes. GAO said the list is limited to 136 because of funding constraints. Homes on the list are more likely to be for-profit, large and operated by chains, GAO said.

Each state also has a "candidate list" of 15 homes that might make the final list, and the GAO said state officials don't always look at the highest rank on that list to pick the worst. They might consider whether the home had a new owner they believe is committed to solving quality problems.

The GAO has said in the past the 136-home list includes the worst homes in every state but not necessarily the worst homes in the nation, and has recommended moving away from the state-by-state approach. An August 2009 report estimated that 4 percent of all homes are among the very worst. The options for homes are to graduate from the list, remain on it if improvement is shown — or have participation in Medicare and Medicaid terminated.

The new report says that a "troubling" number of homes remain on the list for longer than the desired 18 months, preventing other problematic homes from being added.

GAO recommendations include telling nursing homes they are at risk of winding up on the SFF list, ensuring that states have more stringent enforcement, such as higher monetary penalties.

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Georgia Backs Out of New Law's High-Risk Insurance Pool

By Jane Norman, CQ HealthBeat Associate Editor

April 12, 2010 -- The state of Georgia will not establish a high-risk pool to provide health insurance coverage for people with pre-existing conditions, the state's insurance commissioner announced Monday.

Commissioner John Oxendine said in a statement that he was concerned that the state could become financially responsible at some point for the pool, though the program is envisioned as temporary under the new health care law (PL 111-148). The high-risk pools are supposed to be funded by grants made to states.

"I have no confidence in any federal assertion that this so-called temporary program will not burden the taxpayers of Georgia," he said in a statement. "I am concerned that the high-risk insurance program will ultimately become the financial responsibility of Georgians at a time when our state is furloughing teachers, laying off employees, and cutting public safety and education funding."

The reaction comes from a state where Republican lawmakers have been particularly outspoken about their opposition to the new law.

Oxendine, a Republican, is running for governor and is an advocate of challenging the law's constitutionality. Georgia Gov. Sonny Perdue, also a Republican, recently announced the state would join 18 other states in a legal challenge. He vowed to use private lawyers after the state's Democratic attorney general refused to join the suit.

Health and Human Services Secretary Kathleen Sebelius wrote to states on April 2 asking what their interest would be in extending insurance through high-risk pools to people with pre-existing conditions who have lacked insurance for at least six months. The $5 billion program is intended to be temporary until 2014, when insurance companies will be required to accept all comers regardless of their health status.

If Georgia declines to participate, the federal government can directly set up a pool under the law so the uninsured have an option, said Jeanne Lambrew, director of the Health and Human Services Department's Office of Health Reform.

"For too long, people with pre-existing conditions have been locked out of the insurance market, including some people in Georgia," Lambrew said. "If state officials in Georgia elect not to participate in the high-risk program, our department will work to ensure that people in Georgia as well as other states that don't participate have access to affordable insurance."

Oxendine blasted what he called a "federal takeover" of the health care system. "The new federal health care legislation was hastily drafted behind closed doors and passed as a result of numerous back room deals in defiance of the will of a majority of the American people," he wrote in a letter to Sebelius.

Currently 35 states run high-risk pools, though not all are accepting new members, and they serve about 200,000 people. Often the premiums are very expensive. Premiums would be cheaper in the new program because of the federal subsidy.

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HHS Warns of 'Disturbing' Trends in Hospital-Associated Infections

By Jane Norman, CQ HealthBeat Associate Editor

April 13, 2010 -- A new report issued Tuesday by the Department of Health and Human Services pinpoints "disturbing" findings when it comes to infections acquired in hospital settings and warns such infections are on the rise in the United States. Rates of postoperative sepsis, or bloodstream infections, and catheter-associated urinary tract infections top the list.

Sepsis is a life-threatening infection that kills a third of those who contract it, while urinary tract infections generally are treatable with antibiotics but still troubling when combined with other problems in a hospitalized patient.

"In hospitals, safety remains a significant problem," says the report by the Agency for Healthcare Research and Quality (AHRQ), adding that it is "unfortunate" that rates of healthcare-associated infections are not declining and little progress is being made.

Overall, the report concludes that health care quality in all settings is improving slowly, especially for preventive care and chronic disease. The uninsured remain less likely to receive needed care.

HHS Secretary Kathleen Sebelius told reporters in a conference call that the problem with hospital infections is "incredibly serious" and that as many as 100,000 deaths annually are due to hospital infections. Provisions in the new health care law (PL 111-148) enacted by President Obama will start to address the problem by reducing reimbursements under Medicare for certain conditions acquired while under hospital care, as well as preventable re-admissions.

Sebelius said there are proven strategies for reducing infections — they are just not in place in hospitals in most parts of the country. "Eventually there will be a financial disincentive for hospitals that don't take this very seriously," said Sebelius, citing the new law.

The figures on infections are included in the National Healthcare Quality Report mandated by Congress and issued annually since 2003 that examines U.S. health care quality and includes a new section on infections contracted by patients while in the hospital.

"It is evident that more attention devoted to patient safety is needed to ensure that health care does not result in avoidable patient harm," says the report. Rates of postoperative sepsis, or bloodstream infections, increased by 8 percent between 2006 and 2007, while postoperative catheter-associated urinary tract infections were up by 3.6 percent and selected infections due to medical care were up 1.6 percent.

Unchanged was the number of bloodstream infections associated with central venous catheter placements, which are tubes placed in a large vein to administer medication or fluids or collect blood samples. Rates of postoperative pneumonia did improve by 12 percent.

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said in an interview that hospitals take the issue of patient safety very seriously and have been working on the issue for many years, especially in the past decade since a landmark report on medical errors was issued by the Institute of Medicine.

"With regard to infections, in particular we have taken enormous strides by trying to reduce infections by using the best available science to show us what strategies are likely to work," said Foster. While the data in the AHRQ report is the best currently available, it's still a couple of years old and hospital improvements may not yet be visible in data, she said.

The rate of increase in sepsis documented in the report was surprising, Foster said, perhaps because the data is being collected and analyzed more so than in the past. At the same time hospitals fared well in the AHRQ report on processes tied to reducing infections, such as timely administration of antibiotics. "That leaves us sort of wondering — what are the other things we need to be doing consistently?" Foster said. "We don't have that answer. If we did, we would be implementing that."

More basic research – and government support for it – is needed at the Centers for Disease Control and the National Institutes of Health to help provide some of the solutions, Foster said.

Carolyn Clancy, director of AHRQ, said that generally, U.S. health care quality is improving though the pace is too slow. Overall, across all settings, measures of health care quality are improving at about 2.3 percent a year and 5.8 percent a year in hospitals, she said. Outpatient care is improving at 1.4 percent annually. "Though the trends are good the pace is unacceptably slow," said Clancy.

Focused attention on reducing hospital infections can work dramatically as has been evidenced through a government-funded project over three years in intensive care units in Michigan ranging from small rural facilities to academic centers, said Clancy. All of them adopted standardized procedures and reduced the rates of central line-associated bloodstream infections to nearly zero. The project will be expanded to all 50 states, the District of Columbia and Puerto Rico. "This became part of the fabric of delivery of care in these hospitals," she said.

A second mandated report, the 2009 National Healthcare Disparities Report, found that members of minority groups and low-income Americans, especially those without insurance, continue to lag when it comes to quality health care. Many of the disparities are not decreasing, said Howard K. Koh, assistant secretary of health. Reducing disparities means more emphasis on raising awareness and improving training and communication, said Koh. Sebelius said the new law will help by creating a new national institute on minorities and minority health and mandating new data on disparities.

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Lawmakers Complete Action on a Physician Rate Extension

By Paul Jenks

April 16, 2010 -- After a week of debate, an extension bill clears both chambers and is signed by the president while lawmakers begin to dig into the details of the new health care overhaul law.

Weekly Review
The Senate spent the entire week haggling over a delayed program extension bill (HR 4851) that only extended programs into next month. Included in the bill, but overshadowed by the more visible unemployment compensation extension provisions, is an extension of a reprieve from Medicare physician payment decreases. CQ HealthBeat reported that physicians were growing anxious by Thursday as the decreases technically began on April 1 and the original measure extended the period only until April 30. A Senate substitute amendment adjusted the extension to May 31. Senators adopted the revised measure on Thursday evening and the House quickly approved the bill two hours later. The president signed the measure before midnight.

The debate on the bill replicated some of the same Republican spending objections to an earlier extension bill (HR 4691) in March. A different longer-term extension bill (HR 4213) approved by both chambers but in different forms awaits a bicameral conference or leadership agreement on a final version. The cost of extending relief from the physician rate scheme for one month is pegged at over $2 billion.

The start of implementation of provisions of the health care overhaul law (PL 111-148) began in earnest this week. CQ HealthBeat reported Monday that the Department of Health and Human Services and other agencies released early rulemaking requests for comments on monitoring health insurance premium rate increases and insurance company reporting on medical loss ratios. HealthBeat reported Wednesday on new legislation that would extend older children's coverage provisions to veterans' health plans and CQ reported Monday that the Senate was able to quickly pass a measure that assured the inclusion of current military health plans (HR 4887). HealthBeat reported Thursday that Supreme Court Justice Stephen G. Breyer said he expects the health care overhaul law will be tested in the high court.

Also, CBO Director Douglas Elmendorf in a presentation this week revisited the CBO budgetary analysis of the health law and a CRS memorandum from last week detailed uncertainties about congressional health coverage provisions for lawmakers and staff. Additionally, House Energy and Commerce Chairman Henry A. Waxman, D-Calif., canceled a planned hearing next week on corporate write-offs caused by the health care overhaul law and released a preliminary report on corporate financial reporting on changes to retiree prescription drug benefits.

Coming up on lawmakers' agenda is the fiscal 2011 budget resolution. Early this week CQ reported on uncertainty that a budget blueprint will be crafted this year but another report on Wednesday noted that the Senate would start action on its resolution before the end of May. The resolution sets the funding levels for the regular appropriations bills and may include instructions for new reconciliation legislation, which was a critical tool that allowed the health care overhaul program to pass both the House and Senate last month.

Congressional committees met on several health issues this week. HealthBeat reported on a House Energy and Commerce session on smokeless tobacco use in baseball, and other sessions were held on children's nutrition programs, specialized defense health facilities and appropriations for the Indian Health Service.

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Next Challenge: Meeting Demand for Primary Care

By John Reichard, CQ HealthBeat Editor

April 16, 2010 -- Lawmakers worked very hard this session to guarantee Americans access to health insurance under the new overhaul law, but they'd better not relax now if they want to make sure Americans actually get the care they need.

Several provisions of the law (PL 111-148) were written to prepare for an expected surge in demand for primary care when millions of uninsured Americans get insurance cards in 2014.

But because a number of those programs must be funded through annual appropriations, primary care champions such as Rep. Henry A. Waxman, D-Calif., will have to keep an eye on the programs to make sure they get enough money. If not, consumers' complaints about difficulties finding a doctor, which analysts say are inevitable anyway as coverage expands, will only grow a lot worse.

Sick as they might be of all things health care, lawmakers will have to vote for billions in spending beyond the almost $1 trillion the law is already expected to cost in the next decade.

"Primary care" refers to treatment that takes care of all medical problems except those too rare for the physician involved to maintain competence. It's delivered through general internists, general pediatricians, and family physicians who, ideally, keep close tabs on a patient over many years and can prevent, delay, or lessen complications from major illnesses.

A Surfeit of Specialists
Experts say it's the type of care that too often is missing from the American health system with its surfeit of specialists relying on expensive tests and procedures and their responsibility for specific parts of the body and diseases rather than the overall well-being of the patient. And its absence has consequences.

"Infant mortality goes up, life expectancy goes down, and all these things are demonstrable, they don't take long to occur," says Barbara Starfield, a professor and primary care researcher at Johns Hopkins University.

University of Missouri researchers in 2008 predicted a shortfall of up to 44,000 doctors by 2025 to meet adult primary care needs. That was before the new law. With so many Americans gaining coverage in the next decade, that estimate is now low, says Robert Doherty, an official with the American College of Physicians.

When 440,000 Massachusetts residents gained coverage under that state's 2006 overhaul law, primary care too often wasn't available. Access remains difficult, according to a September 2009 survey by the Massachusetts Medical Society. The percentage of family medicine doctors no longer taking new patients increased from 30 percent in 2007 to 40 percent in 2009. And the percentage of internal medicine doctors no longer accepting new patients grew from 49 percent to 56 percent. On average, new patients had to wait 44 days for appointments in 2009.

Doherty says the new law will ease the crunch nationally by expanding primary care training in medical schools, creating more residency slots in primary care, and boosting Medicare and Medicaid payments to primary care physicians.

He says the rewards of primary care will become more apparent as training shifts into community health centers.

A big expansion of the National Health Service Corps and of community health centers will allow many more students to enter primary care by subsidizing their education costs if they practice for a time in medically underserved areas, Doherty adds.

Programs to boost the "medical home" concept will help further a more team-oriented approach to managing patients who are chronically ill and create new revenue streams for physicians. Provisions to streamline payment transactions with insurers will also help keep older primary care doctors in practice, he says.

But Lori J. Heim, president of the American Academy of Family Physicians, says that fewer than half of family physicians will get the 10 percent bump in Medicare payments under the law because its definition of primary care is too tight. And a provision to boost very low Medicaid payment rates to higher Medicare levels isn't as attractive as it seems because of the perpetual threat of physician payment cuts in Medicare.

To keep this mix of primary care policies in place, lawmakers will have to approve tens of billions in new spending in the next decade. For example, the Medicaid rate hike is only in 2013 and 2014 — but over ten years its cost would total $57 billion.

The cost underscores the importance of provisions of the law to save money by encouraging research identifying which medical treatments actually work, says Ann S. O'Malley, a primary care analyst with the Center for Studying Health System Change.

Whatever the limits of the primary care provisions, Heim says they are a platform on which Congress can build. Starfield said a similar mix of policies adopted by lawmakers in 1976 fueled a decade of growth in primary care, and she sees signs that young medical students are beginning to respond to the new signals Congress is sending.

"This year for the first time in many years residency positions in family medicine are over 90 percent filled. Amazing," she said.

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Sebelius Launches Implementation of Medical Loss Ratio Regs

By Jane Norman, CQ HealthBeat Associate Editor

April 12, 2010 -- Health and Human Services Secretary Kathleen Sebelius took the first steps Monday toward implementing the new health care law's provisions dealing with medical loss ratios — how much insurers must spend on paying out medical claims, as opposed to other expenses such as administration, ads or salaries.

Sebelius also made it clear that she wants the regulations on medical loss ratios up and running sooner than later. In a letter, she asked members of the National Association of Insurance Commissioners (NAIC) to send her their guidance by June 1 on how to put the new law in place.

The target date in the law (PL 111-148) for such advice was Dec. 31, but Sebelius noted in her letter that the medical loss ratio provisions are effective for plan years beginning six months after the law's enactment. HHS wants to publish regulations "as soon as possible" to allow enough time for insurers to incorporate the changes, she said.

Under the health care law, insurance plans must specify what percent of premium revenue is spent annually on reimbursement for clinical services, activities that improve health care quality and all other non-claims costs. Enrollees will receive rebates if the minimum is less than 85 percent. Reports will be made available on the Internet.

"One of the central goals in health insurance reform is to make premiums affordable," Jeanne Lambrew, head of the Health and Human Services Department's Office of Health Reform, said in a conference call with reporters. "To begin to tackle affordability, the administration today is taking its first steps toward oversight of health insurers' administrative overhead, growth rates and premium increases."

Lambrew said NAIC agrees with the department that the medical loss ratio regulations need to be established quickly. Some states already conduct medical loss ratio reviews and have their own definitions, and the department is looking for input about what's common practice, Lambrew said.

Sebelius said in her letter that the "strong partnership" between the department and NAIC has been of great benefit and the federal government will continue to reach out to states as implementation of the new law continues. Thus, the Health and Human Services Department (HHS) is looking for input from NAIC on how to define what's included in medical loss ratios and standardized calculation methodologies, ensuring they account for smaller insurance plans, different types of plans and newer plans, she said.

In addition, HHS published requests in the Federal Register for public comment within 30 days on the definition of medical loss ratio, as well as public comment on separate rate review provisions.

On rate review, HHS in conjunction with states will set up a process to annually review insurance company rate increases and determine whether they are unreasonable. Additionally, insurers have to give HHS and the relevant state a justification for an unreasonable premium increase prior to the implementation of the increase, and prominently post this information on their Internet Web sites.

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