Poll Proves Medi-Cal Patients Access Already Compromised

Independent firm Fairbank, Maslin, Maullin, Metz & Associates (FM3) recently conducted a survey of California adults to measure their use of health care, attitudes toward their health coverage, and reactions to proposed health care policy changes. Specifically, the survey was done to determine access to care that Medi-Cal patients currently have compared to privately and uninsured patients across the state.

“The data presented in this survey is a clear indication that patients’ needs aren’t being met with the current system,” Dustin Corcoran, the California Medical Association (CMA) CEO said. “California needs to be an example for health care reform in this country, and limiting patient access while reducing provider resources is a recipe for disaster. The proposed cuts that have been submitted by the Department Health Care Services (DHCS) to the Centers for Medicare & Medicaid (CMS) are a clear violation of federal law. Access to care must be equal for Medi-Cal and privately insured patients and the facts are here- they’re simply not.”

The survey was conducted after DHCS submitted state plan amendments (SPAs) that would reduce Medi-Cal reimbursements by 10%, limit patient visits and impose mandatory patient co-payments.

“Medi-Cal patients already are disadvantaged in obtaining health care and these payment cuts will make it worse,” C. Duane Dauner, the CEO of the California Hospital Association said.

Key findings of the survey as reported by the independent pollster include:

• There are significant disparities in health status and access to primary care between Medi-Cal patients and other Californians.
• When Medi-Cal patients needed health care, only half received it, compared to nearly 75% of privately insured patients.
• Medi-Cal patients are far more likely than other Californians to be turned down by a physician who would not accept Medi-Cal payment.
• Medi-Cal patients are more than four times more likely to get care in a hospital emergency room because they could not get an appointment with a doctor or clinic.

Click here for the survey summary.

HHS Releases Final Regulations For Accountable Care Organizations

The Department of Health and Human Services (HHS) released its much-awaited final rule for Medicare accountable care organizations (ACO), which make it easier for doctors and hospitals to participate by cutting in half the number of performance measurements, removing the electronic health records requirement and eliminating financial risks for some groups.

To entice providers, CMS said it will make $170 million available starting next year to physician-owned and rural providers to start ACOs.

A move to ACOs has been seen as one of the most promising new models of delivering health care since it would reward doctors and hospitals for providing high-quality care to Medicare beneficiaries while keeping costs down. Today, hospitals and doctors generally get paid more for delivering more care, not necessarily better care.

Key Changes Included in Final Rule

• Providers will be able to participate in an ACO and share in savings with Medicare without risk of losing money. ACOs will be able to start sharing in the savings earlier rather than letting Medicare retain all the initial savings.

• The number of quality measures that ACOs will have to meet to qualify for performance bonuses was reduced from 65 to 33.

• The ACOs will be told up-front which Medicare beneficiaries are likely to be part of their system. Under the earlier rule, ACOs would not know which patients were in the ACO until their contract ended.

• Community health centers and rural health clinics will be allowed to lead ACOs. They were left out of the prior proposal.

Regulators estimate that between 50 and 270 ACOs would be formed in the next three years, affecting the care of 2 million of the 47 million Medicare beneficiaries.

Medicare beneficiaries will be assigned to an ACO based on who their doctor is. If a patient’s doctor is part of an ACO, that patient is automatically included, although the beneficiaries can choose to not be included by opting to keep their records outside the ACO system.

Unlike beneficiaries in Medicare HMOs, patients in ACOs are free to visit any health care provider, just as they are in the traditional Medicare program.

ACOs aim to improve care and save money by having doctors, hospitals and other providers better coordinate their services to among other things reduce unnecessary emergency room use and reduce hospital readmissions.

But the government’s efforts to push hospitals and doctors to work more closely together has raised anti-trust issues.

Actuaries for CMS anticipate that the program could save Medicare $940 million over four years —a drop in the bucket compared to the $2 trillion Medicare anticipates spending during this period. ACO proponents, however, hope that the new organizations would proliferate and be expanded both for Medicare beneficiaries and privately insured patients.

When administration officials released their preliminary rule last spring, hospital and doctor groups complained that the program created more financial risks than rewards and imposed onerous reporting requirements. The American Medical Group Association, which represents nearly 400 large provider organizations, told CMS officials in a letter that more than 90 percent of its members would not participate. In particular, industry groups objected to a provision in the proposed rule that would impose penalties for ACOs that do not achieve savings.

Source: Kaiser Health News, October 20, 2011

For More Information

Shared Savings Program final rule

Advanced Payment solicitation

For more information on these two topics, fact sheets are posted at http://www.cms.gov/center/press.asp.

The joint CMS and Department of Health and Human Services Office of Inspector General (OIG) Interim Final Rule with Comment Period addressing waivers of certain fraud and abuse laws in connection with the Shared Savings Program is posted at:  www.ofr.gov/inspection.aspx.

The Antitrust Policy Statement is posted at: www.ftc.gov/opp/aco/ and http://www.justice.gov/atr/public/health_care/aco.html.

The Internal Revenue Service (IRS) Fact Sheet, Tax-Exempt Organizations Participating in the Medicare Shared Savings Program Through Accountable Care (FS-2001-11), will be posted at: http://www.irs.gov (PDF 52 KB).

SFMS Career Fair a Success

The SFMS second annual Career Fair enjoyed a great turnout. On September 27, over seventy residents and fellows from local residency programs connected with recruiters from nineteen exhibiting organizations representing variety of practice types and settings based in San Francisco Bay Area. Many residents felt this was a wonderful opportunity to become acquainted with practice position opportunities and choices available in their specialty in San Francisco Bay Area, and highlight small clinics and groups that may have been overlooked by regional or national job search events.

One event attendee commented, “Thank you for organizing an event that showcases the Bay Area’s local community clinics. This event is unlike any other because of the emphasis on San Francisco Bay Area job opportunities.”

For those that missed the career fair, SFMS will be publishing a list of available positions and recruiter contact information in our November member-only eNewsletter. SFMS is already planning for next year’s event, tentatively scheduled for September 2012 at St. Mary’s Medical Center.

SFMS would like to thank the California Pacific Medical Center for providing the venue for this event. We would also like to recognize our participating exhibitors and staff at the graduate medical departments of CPMC, UCSF, St. Mary’s, and Kaiser Permanente for their generosity and support.

EXHIBITORS

Asian Health Services

Brown & Toland

Cardiovascular Medical Group

Chinese Hospital

CHW Medical Foundation

CPMC/Sutter Health

Haight-Ashbury Free Clinics – Walden House

La Clinica de La Raza

Malin, Aubry, Gores, Wang, Haddad, and Sankaran

Marin Hospitalist Medical Group/Marin General Hospital

My Doctor Medical Group

Native American Health Center

NorthEast Medical Services (NEMS)

One Medical Group

The Permanente Medical Group/Kaiser Permanente

San Francisco Community Clinic Consortium

San Francisco Department of Public Health

Sonora Regional Medical Center

U.S. Health Care System Needs Improvement on Affordability and Access

The U.S. health care system is faltering in areas such as affordability and access even as it gets more expensive, according to the third comprehensive scorecard issued by the Commonwealth Fund, one of the country’s biggest health care foundations. After looking at 42 indicators of health care quality, access, cost, and other values, the fund gave the U.S. a score of 64 out of 100.

The scorecard primarily looked at data from 2007 to 2009, before the health care law was adopted last year, and thus is more of a benchmark of where the country was at the end of the last decade than how it is currently doing. Many of its measures have been reported elsewhere or are well known, such as the rising cost of health insurance. Still, the scorecard provides a rare, big-picture assessment of all the ways the country’s health care system is failing or underperforming, as well as a few ways it has gotten better and areas where it has the most room to grow.

The scorecard found improvements in how well adults got their high blood pressure under control, and how well hospitals were doing in preventing surgical complications and treating heart attacks, heart failure and pneumonia. But it also found an increase in hospitalizations of nursing home patients and shortcomings in the ability of sick adults to quickly get to a doctor without going to the emergency room. It also concluded that the U.S. does dismally in terms of how efficiently it uses health care resources, avoids wasteful treatments, limits administrative costs and uses electronic medical records.

Click here to read the executive summary of the National Scorecard on U.S. Health System Performance, 2011.

Source: Kaiser Health News, October 18, 2011.

Palmetto Conducting Audits of Physician Claims

For the past two years, Palmetto GBA has received payment error rates from the Comprehensive Error Rate Testing (CERT) Contractor that are nearly twice the national rate. A large portion of the errors are attributed to insufficient and illegible documentation, and lack of or illegible signatures. Palmetto is now taking steps to correct these errors by reviewing claims to identify potential areas for provider education.

Palmetto will notify affected physicians by mail that a small sample of their claims will be selected for medical review. The notice will also provide recommended resources on documentation and coding. Physicians who are notified will receive a request for medical records in the form of an Additional Document Request (ADR) for each claim selected, along with an example of the information that should be returned. Failure to respond to these requests will result in non-payment of the claim.

Palmetto may also make unannounced site visits to physician offices to establish a date for an educational meeting. Failure to participate in this education will result in 100 percent pre- and post-payment audit of claims. CMA is discussing the nature of these audits with Palmetto and the disruption and burden they will be to physician offices.

Please check back on the SFMS blog next week for more detailed information.