By Kerry Young, CQ Roll Call

March 31, 2016 -- Health professional societies and consumer groups have asked Medicare to tread carefully while overhauling its system for paying doctors, raising concerns about an agency suggestion to include guidelines from a campaign that seeks to curb the use of often unneeded procedures and treatments.

Medicare officials are awaiting White House clearance of a draft rule designed to tie payments for doctors to judgments about the quality of care they provide. The Office of Management and Budget has been reviewing this proposal since March 25. The Centers for Medicare and Medicaid Services (CMS) rule would carry out the changes mandated in last year's congressional overhaul of Medicare physician payments (PL 114-10).

CMS last year sought public comments on how to design a new payment. In a request for information, the agency raised myriad questions about how the so-called Merit-Based Incentive Payment System program for doctors could be designed.

CMS asked if there might be some benefit to weaving in new system measures from a 2012 initiative known as the Choosing Wisely program, which asked doctors to identify commonly used medical tests, treatments and procedures that may be unnecessary for many patients. More than 70 medical specialty societies have since released recommendations as part of the campaign.

The American Medical Association (AMA) told CMS that it would "premature" to use the Choosing Wisely recommendations to attempt to judge how effectively doctors have prescribed treatments and ordered tests. This phrase was echoed in comments submitted to CMS by at least five other groups, including the American Psychiatric Association.

There's been a trend toward a closer adherence to guidelines in deciding on which treatments may be appropriate for a patient, but these should not be regarded as "absolute recommendations," the AMA told CMS. Exceptions must be allowed, argued James L. Madara, the AMA chief executive officer.

"Presented with the general Choosing Wisely guidelines, a physician or patient may conclude that a particular recommendation is not appropriate in a given circumstance," Madara wrote.

As CMS seeks to curb the overuse of some treatments that provide may little benefit, it needs to make sure it doesn't discourage doctors from getting their patients needed care, wrote David Certner, legislative counsel for the seniors' group AARP, in a comment. Still, AARP would "support efforts to reduce use of overused, low-value tests and procedures, reduce waste in the health care system, and improve quality and safety of care, such as the Choosing Wisely Campaign," Certner wrote. AARP says it has nearly 38 million members.

By Andrew Siddons, CQ Roll Call

March 30, 2016 -- People who gained health insurance through the 2010 health care overhaul seem less healthy than people who previously bought coverage on their own—but the newly insured are only slightly less healthy than workers with job-based coverage, according to a report by the Blue Cross Blue Shield Association (BCBS).

Previously, people with preexisting conditions, if not covered through an employer's plan, often had trouble finding or affording health insurance on their own. But the law banned insurers from charging more or denying coverage because of consumers' health conditions.

Compared to people with employer-provided insurance, individuals who enrolled in health plans through new exchanges starting in 2014 had higher rates of conditions like diabetes, depression and coronary artery disease—but the difference was not dramatic. In 2015, for instance, for every 10,000 newly enrolled members with coverage for individuals, 456 people had diabetes, compared to 424 out of 10,000 members with job-based coverage.

When comparing newly enrolled people with those who bought individual plans before 2014, however, the contrasts are much sharper. Consumers who signed up earlier seem in much better shape—likely because they were healthy enough to obtain and afford individual plans before the health care law made everybody eligible, regardless of their physical conditions. Out of 10,000 members who initially enrolled before the new insurance exchanges opened, only 235 had diabetes in 2015.

Rates of service for newly enrolled individuals were also higher than employer-based group members, but only moderately. For every 1,000 newly enrolled members who bought coverage on their own, there were 83 inpatient admissions and 1,717 outpatient visits. For 1,000 employment-based members, those figures were respectively 60 hospitalizations and 1,554 visits.

The findings seem to suggest that part of President Obama's vision for the health care law is being realized, as patients with preexisting conditions obtain health coverage.

But they also suggest that people may not be taking advantage of the services available to them, including preventive care. The newly enrolled members and those with employer plans both had a higher rate of emergency room visits than the generally healthier people who enrolled in individual plans before 2014. 

Analyzing data from 30 million members of Blue Cross insurance companies, the report found that newly enrolled individuals on average had medical costs of $559 per month in 2015, 19 percent higher than all the members of employer-based groups covered by Blue Cross Blue Shield plans, whose average costs were $457 per month.

The Department of Health and Human Services (HHS) pushed back on the report, saying the comparison between newly insured and previously insured in the individual market was flawed. The department framed the report as evidence for why the health care overhaul was needed in the first place.

The department also argued that the report provided a skewed picture of how consumers covered in the individual market compare to people in employer-provided insurance because it contrasted only newly insured people in the individual market with everyone in job-based BCBS insurance.

HHS also pointed out that in response to predictions that the newly insured would be costlier, the health care law created transitional stabilization programs to help insurers avoid big losses.

By Kerry Young, CQ Roll Call

March 30, 2016 -- Many hospitals are not prepared for the start of a major Medicare effort to tie future payments to judgments about the quality and cost of care delivered in knee and hip replacements, a study indicates.

Avalere Health, a consulting group, on Wednesday released a paper in which it estimated that 60 percent of the hospitals drafted into Medicare's Comprehensive Care for Joint Replacement model may face penalties, based on an examination of how their costs now compare to other hospitals. This knee-and-hip program marks a departure from Medicare's past approach of recruiting volunteers for payment tests. Instead, Medicare has mandated that about 800 hospitals in 67 selected regions of the country participate in this test, which will dole out financial rewards and punishments based on how well people fare after surgery.

The rules by the Centers for Medicare and Medicaid Services (CMS) may skew the participants to include more hospitals that have been so far been timid about trying ways to better coordinate patient care after treatments. CMS spared from the hip-and-knee program certain hospitals that already participate in another of its payment tests, the Bundled Payments for Care Improvement model. This exempt group includes many early adopters and "poster children for accountable care" models in many cases, said Fred Bentley, a vice president of Avalere, in a Wednesday interview.

"It's the other hospitals that maybe have been waiting on the sidelines" that are being compelled to participate in the hip-and-knee program, Bentley said.

During the first year, which starts Friday, the program will not impose penalties, only potential rewards, based on judgments about performance. The program runs through the end of 2020.

Medicare spends about $7 billion a year on hip and knee replacements. CMS said last year that it anticipates saving Medicare a total of $343 million from the program, with some hospitals standing to gain and others to lose. The judgments will be based in part on how well patients fare from the time of their admission to 90 days following their discharge.

Rep. Tom Price, R-Ga., is seeking to delay the start of the hip-and-knee test. He on March 23 introduced a bill (HR 4848) that would hold off the implementation until 2018. He so far has drawn one cosponsor, Rep. David Scott, D-Ga.

The hip-and-knee test program represents an effort by CMS to jump start efforts to better coordinate the care of people on Medicare after many kinds of surgeries and major illnesses, Bentley said.

"They are very much trying to move away from traditional fee-for-service, where there are no strings attached" to payment, he said. "There is no accountability for cost and quality beyond the hospitals' four walls."

Treatment after an injury or illness, known as post-acute care, represents a roughly $60 billion annual expense for Medicare. Lawmakers have mulled for some years how to restructure the fragmented approach to post-hospital care, with different kinds of nursing centers often receiving higher pay for similar treatment. People on Medicare and their families often face stressful choices about where someone should go for post-hospital care, as there often is little information available to weight potential benefits and drawbacks of use treatments delivered at home compared with those provided in skilled nursing and specialty inpatient rehabilitation facilities.

By Kerry Young, CQ Roll Call

March 28, 2016 -- Many people struggling with opioid abuse would be helped if more states expand their Medicaid programs and provide another route to treatment for those with severe disabilities, a top Obama administration official said.

The Department of Health and Human Services (HHS) on Monday tried again to make a case for expanding the health program for the poor in the 19 states that have not yet done so. There are about 1.9 million people who have a substance abuse disorder or mental illness that potentially could be helped through a Medicaid expansion but who often earn too much to be eligible, HHS said Monday in a report. People fighting tough addictions cannot qualify for federal Social Security disability insurance (SSDI) benefits, which can include entry into the Medicare program before age 65, according to Richard Frank, assistant secretary for planning and evaluation at HHS.

"There's a law that was passed many years ago that means that you cannot qualify for SSDI on the basis of a substance abuse disorder," Frank said on a Monday call with reporters.

The new HHS appeal comes amid continued efforts to address the nation's opioid crisis. The Senate on March 10 passed 94-1 a bill from Sen. Rob Portman, R-Ohio, intended to bolster federal efforts to prevent and combat drug addiction. Widespread use of narcotic painkillers has been identified as a gateway that has led many Americans to heroin.

The Medicaid expansion, though, remains a highly partisan issue, with Republican governors and lawmakers opposed to short-term incentives in the 2010 health law to allow more people to enroll. Louisiana, where a Democratic governor took office this year, is in the process of expanding its Medicaid program, HHS noted in its report.

Expansion of the Medicaid program in more states also would help people who are coping with chronic mental illness and and may struggle to buy insurance. The group includes people suffering from anxiety disorders, depression, bipolar disorder, and even schizophrenia. Frank said.

"You have a full range from some of the most common mental disorders to some of the most significant and disabling ones," Frank said.

By Kerry Young, CQ Roll Call

March 29, 2016 -- Two House committees on Tuesday issued subpoenas to the Department of Health and Human Services seeking information about $1.3 billion that they say was provided for implementing part of the Affordable Care Act without first securing a needed appropriation.

House Ways and Means Chairman Kevin Brady, R-Texas, and Energy and Commerce Chairman Fred Upton, R-Mich., each intend to compel HHS Secretary Sylvia Mathews Burwell to appear to address funding of the Basic Health Program. The program was created by the 2010 health law to give states the ability to provide more affordable coverage for people living in or near poverty. 

Both subpoenas call for an April 12 appearance.

"We've been trying to get answers since last June, but HHS simply will not cooperate. The administration funneled $1.3 billion last year into the Basic Health Program without a congressional appropriation—a clear violation of the law," Brady and Upton said in a statement. "Our good faith attempts to learn basic, and targeted facts have been met with resistance every step of the way."

The program is an option for states to use federal dollars to subsidize coverage for people whose income is between 139 percent and 200 percent of the poverty line.

The top Democrats on these House committees were quick to criticize their GOP counterparts.

"This partisan attack is a waste of taxpayer dollars, and points to an abuse of House Republicans' ability to unilaterally issue subpoenas," said Rep. Frank Pallone Jr. of New Jersey, the top Democrat on the Energy and Commerce panel, and Sander Levin of Michigan, the top Democrat on the Ways and Means panel. "Committee chairmen on both sides of the aisle have long recognized that subpoenas should be used as a last resort, not simply to add fuel to political fights."