Trustees Report Shows Medicare Remains Viable, But Challenges Remain

The Medicare Trustees Report released today shows that while Medicare remains solvent longer than expected prior to passage of the Affordable Care Act, challenges remain for securing the long term financial health of the Medicare program. Expenditures for the Supplementary Medical Insurance (SMI) Trust Fund were lower than expected this year. The Trustees annual report says that Medicare’s Hospital Insurance (HI) Trust Fund is now projected to remain solvent until 2024.

Without the reforms in the Affordable Care Act, the Medicare HI Trust Fund would expire in just five years – in 2016. The report issued today shows these reforms added eight years of solvency.

“This report shows that without the Affordable Care Act, the outlook for the Hospital Insurance Trust Fund today would be much worse, said Donald Berwick, M.D., Administrator of the Centers for Medicare & Medicaid Services. “CMS is implementing critical reforms to improve care and reduce costs and improve the overall health of Medicare’s beneficiaries and the Trust Fund.”

Actual Part B expenditure growth in 2010 was lower than expected. Part B is funded by a combination of beneficiary premiums and general revenue financing.

Part D, the Medicare prescription drug program, is also in financial balance as a result of annual updating of enrollee premiums and benefit payments. Projected expenditures are slightly lower overall than in last year’s report, reflecting lower-than-expected costs in 2009 and 2010 together with a reduction in the projected growth in prescription drug spending in the U.S. for the next 10 years.

HI Trust Fund expenditures have exceeded income annually since 2008 and are projected to continue doing so under current law in all future years. Interest earnings and asset redemptions are required to cover the difference. HI Trust Fund assets are projected to cover annual deficits through 2023, with asset depletion beginning in 2024.

The five year change from the 2010 trustee report was due to a slowdown in the national economy, which resulted in a decline in tax revenues and higher real projected expenditures. This is not the first time that the HI Trust Fund expiration date has been affected by a decline in anticipated revenues. In 2004, for example, the Trust Fund exhaustion date moved up by 7 years, in large part because payroll tax revenues in 2003 were lower than had been anticipated.

The projections in this year’s report demonstrate the importance of the Affordable Care Act as a tool to improve the outlook for the HI Trust Fund but also point to a need to continue serious discussions about driving care improvements that also address underlying cost drivers in the Medicare program.

The Medicare Trustees are Treasury Secretary and Managing Trustee Timothy F. Geithner, Health and Human Services Secretary Kathleen Sebelius, Labor Secretary Hilda L. Solis, and Social Security Commissioner Michael J. Astrue. The two public representatives appointed by the President and confirmed by the Senate, are Charles P. Blahous III and Robert D. Reischauer began serving on September 17, 2010. CMS Administrator Berwick is designated as Secretary of the Board.

The report is available at: http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2011.pdf

HHS to Insurers: Double-Digit Rate Hikes Will Prompt Review

The Department of Health and Human Services (HHS) has released a final rule that will allow states to scrutinize insurance companies if they propose excessive increases in insurance premiums.

The final rule, published Thursday, would give states the authority beginning in September to issue a review of any insurer that raises premiums for small or individual health insurance plans by more than 10% in a given year. The law does not, however, give states or the federal government the power to tell an insurance company that it can't enact a high rate hike.

Part D Plans Generally Cover Drugs Commonly Used By Dual Eligibles-DHHS OIG

Download the complete report (PDF)
Adobe Acrobat Reader is required to view PDF files. Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.

This report was mandated in the Patient Protection and Affordable Care Act of 2010.

Dual eligibles are individuals who are eligible for both Medicare and Medicaid. Overall, we found that the rate of Part D plan formularies' inclusion of the 191 drugs commonly used by dual eligibles is high, with some variation. On average, Part D plan formularies include 96 percent of the 191 commonly used drugs. In fact, 90 percent of dual eligibles are enrolled in Part D plans that use formularies that include at least 90 percent of the commonly used drugs.

Dual eligibles are a particularly vulnerable population. Overall, they are in worse health than the average Medicare beneficiary and typically require and use more prescription drugs, and more health care services in general, than other Medicare beneficiaries.

To control costs and ensure the safe use of drugs, Part D plans are allowed to establish formularies from which they may omit drugs from prescription coverage and control drug utilization through utilization management tools. These tools include prior authorization, quantity limits, and step therapy. CMS annually reviews Part D plan formularies. CMS also assesses the utilization management tools present in each formulary.

We found variation in the rate at which Part D plan formularies apply utilization management tools to the drugs commonly used by dual eligibles. Some Part D plan formularies apply these tools to none of the commonly used drugs, whereas others apply these tools to 45 percent of the commonly used drugs.

We make no recommendations in this memorandum report. However, we have provided CMS the list of 200 drugs commonly used by dual eligibles for its reference.

New Flexibility for States to Improve Medicaid and Implement Innovative Practices

The U.S. Department of Health and Human Services (HHS) today announced four initiatives to give states more flexibility to adopt innovative new practices and provide better, more coordinated care for people with Medicaid and Medicare while helping reduce costs for states and families. The initiatives support the Obama administration’s work to make Medicaid more flexible and efficient and to address long-term cost growth. Several of the announcements also help implement provisions of the Affordable Care Act. Today HHS announced:

•Fifteen states will receive federal funding to develop better ways to coordinate care for people with Medicare and Medicaid coverage, also known as dual eligibles, who often have complex and costly health care needs.

•All states will receive increased flexibility to provide home and community-based services for more people living with disabilities.

•All states are eligible to receive more money to develop simpler and more efficient information technology (IT) systems to modernize Medicaid enrollment.

•A proposal by the state of New Jersey for flexibility to expand health coverage for nearly 70,000 low-income residents has been approved.

“Medicaid programs provide health coverage for millions of low-income Americans who otherwise would lack access to health care,” said HHS Secretary Kathleen Sebelius. “With these new resources and flexibilities, states will have new options to make their Medicaid programs work better for the people they serve, while helping lower their costs.”

Coordinated Care for People with Medicare and Medicaid

Under a new initiative funded by the Affordable Care Act, 15 states will receive up to $1 million each to develop new ways to meet the often complex and costly medical needs of the approximately nine million Americans who are eligible for both the Medicare and Medicaid programs, known as “dual eligibles.” The goal of the program is to eliminate duplication of services for these patients, expand access to needed care and improve the lives of dual eligibles, while lowering costs. The new Federal Coordinated Health Care Office, or the Duels Office, at the Centers for Medicare & Medicaid Services (CMS), was created by the Affordable Care Act to improve care for dual eligibles and will work with the states to implement the top strategies to coordinate primary, acute, behavioral and long-term supports and services for dual eligibles, improving quality and lowering costs.

The 15 states that will receive these funds are California , Colorado , Connecticut , Massachusetts , Michigan , Minnesota , New York , North Carolina , Oklahoma , Oregon , South Carolina , Tennessee , Vermont , Washington and Wisconsin .

“Beneficiaries who are in both Medicare and Medicaid can face different benefit plans, different rules for how to get those benefits and potential conflicts in care plans among providers who do not coordinate with each other,” said Donald M. Berwick, M.D., administrator of CMS. “This can be disastrous for those beneficiaries who are most vulnerable and in need of help.”

Helping People with Disabilities Live in their Communities

CMS proposed new rules today giving states new flexibility for their programs to help people with disabilities choose to live in their communities rather than in institutions. The proposed rules reduce administrative barriers for states seeking to help multiple populations, which may include seniors and/or people with different types of disabilities. They will also allow individuals to participate in the design of their own array of services and supports, including such things as personal care and respite services for caregivers.

“These long awaited rules will help people living with disabilities realize the promise of the ADA to live in the least restrictive environments possible for them—like their own homes,” said Henry Claypool, director of the Office on Disability at HHS. “With these new tools as well as incentives included in the Affordable Care Act, states, working closely with advocacy groups, beneficiaries, and other stakeholders, can more easily develop effective plans to improve options for people with disabilities. We hope states will take advantage of this new flexibility.”

The proposed rule, CMS-2296-P, can be found at www.ofr.gov/inspection.aspx.

Developing and Upgrading Medicaid IT Enrollment Systems

New rules issued today will provide 90-percent of the cost for states to develop and upgrade their IT systems to help people enroll in Medicaid or the Children’s Health Insurance Program (CHIP) – and

75-percent of ongoing operational costs. This increase over the previous federal matching rate of

50-percent will help states prepare for the Medicaid improvements and expansion that will come in 2014 from the Affordable Care Act, when many more Americans will be eligible for these programs, and to coordinate enrollment with the Exchanges. The rules establish performance standards for the improved eligibility systems to promote greater efficiency and a more consumer-friendly enrollment process.

The final regulation, CMS-2346-F, can be found at www.ofr.gov/inspection.aspx.

Expanding Health Coverage in New Jersey

HHS Secretary Kathleen Sebelius today approved a Section 1115 demonstration for New Jersey that will expand health coverage to nearly 70,000 uninsured, low-income people through the Work First New Jersey program. In addition, the state will increase care coordination to improve health outcomes for participants in the program.

“This demonstration is yet another example of the many flexibilities states have to adapt their Medicaid programs to better serve their residents,” said Secretary Sebelius. “I want to commend New Jersey for expanding coverage to people in need.”

For more information about these announcements, visit www.cms.gov/apps/media/fact_sheets.asp.

OIG Posts New Information on Accountable Care Organizations

On March 31st, OIG posted new information on Accountable Care Organizations. Thhe links provided below will take you directly to the new material.

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Federal Agencies Address Legal Issues Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program
http://oig.hhs.gov/fraud/aco.asp

Today, as part of a cross-agency, coordinated effort, several Federal agencies issued documents addressing legal issues regarding Accountable Care Organizations participating in the Medicare Shared Savings Program
(Shared Savings Program).

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that would establish accountable care organizations (ACO) under the Shared Savings Program. The CMS proposed rule is available online at
http://www.cms.gov/sharedsavingsprogram

CMS and HHS Office of Inspector General (OIG) jointly issued a notice with comment period outlining proposals for waivers of certain Federal laws-the physician self-referral law, the anti-kickback statute, and certain provisions of the civil monetary penalty law-in connection with the Shared Savings Program. CMS and OIG are also asking for comments on further waiver design considerations for the Shared Savings Program and for the separate waiver authority for the Center for Medicare and Medicaid Innovation under section 1115A of the Social Security Act. The joint notice with comment period is available online at
http://www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1

The Federal Trade Commission and the Department of Justice jointly issued a "Proposed Statement of Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program" (Antitrust Policy Statement). The Antitrust Policy Statement is available online at:
http://www.ftc.gov/opp/aco/
 
And the Internal Revenue Service (IRS) issued a notice requesting comments regarding the need for guidance on participation by tax-exempt organizations in the Shared Savings Program through ACOs. The IRS notice
is available online at
http://www.irs.gov/newsroom/article/0,,id=222814,00.html

National Quality Strategy Will Promote Better Health, Quality Care for Americans

Image via WikipediaCreated under the Affordable Care Act, first-ever strategy will guide local, state and national efforts to improve quality of care The U.S. Department of Health and Human Services (HHS) today released the National Strategy for Quality Improvement in Health Care (National Quality Strategy).

The strategy was called for under the Affordable Care Act and is the first effort to create national aims and priorities to guide local, state, and national efforts to improve the quality of health care in the United States.

"The Affordable Care Act sets America on a path toward a higher quality health care system so we stop doing things that don't work for patients and start doing more of the things that do work," said HHS Secretary Kathleen Sebelius. "American hospitals, doctors, nurses and other health care providers are among the best in the world. With this ground-breaking strategy, we are working with local communities and health care providers to help patients and improve the health of all Americans."

The National Quality Strategy will promote quality health care that is focused on the needs of patients, families, and communities. At the same time, the strategy is designed to move the system to work better for doctors and other health care providers - reducing their administrative burdens and helping them collaborate to improve care. The strategy presents three aims for the health care system:

. Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.

. Healthy People and Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social, and environmental determinants of health in addition to delivering higher-quality care.

. Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

To help achieve these aims, the strategy also establishes six priorities, to help focus efforts by public and private partners. Those priorities are:

. Making care safer by reducing harm caused in the delivery of care.

. Ensuring that each person and family are engaged as partners in their care.

. Promoting effective communication and coordination of care.

. Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.

. Working with communities to promote wide use of best practices to enable healthy living.

. Making quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

The strategy was developed both through evidence-based results of the latest research and a collaborative transparent process that included input from a wide range of stakeholders across the health care system, including federal and state agencies, local communities, provider organizations, clinicians, patients, businesses, employers, and payers. This process of engagement will continue in 2011 and beyond.

The National Quality Strategy is designed to be an evolving guide for the nation as we continue to move forward with efforts to measure and improve health and health care quality. HHS will continue to work with stakeholders to create specific quantitative goals and measures for each of these priorities. In addition, as different communities have different needs and assets, the strategy and HHS will empower them to take different paths to achieving these goals.

The National Quality Strategy is just one piece of a broader effort by the Obama Administration to improve the quality of health care, and will serve as a tool to better coordinate quality initiatives between public and private partners. For example, the Affordable Care Act established a new Center for Medicare and Medicaid Innovation that will test innovative care and service delivery models. These new models are being tested to determine if they will improve the quality of care and reduce program expenditures for Medicare, Medicaid, and the Children's Health Insurance Program (CHIP).

Read the report at www.HealthCare.gov/center/reports.

For more information about the National Quality Strategy, visit www.ahrq.gov/workingforquality/.

Affordable Care Act Supports States in Strengthening Community Living

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Yesterday Health and Human Services (HHS) Secretary Kathleen Sebelius announced that nationally, $4.3 Billion in new funds will be provided to help establish and expand community-based alternatives to institutional long term care.  Through the Affordable Care Act (ACA) 13 states will receive additional funding for two programs, the Money Follows the Person (MFP) demonstration program and the Community First Choice Option program, in support of the goal to help move Medicaid beneficiaries out of institutions and into their own homes or other community settings now and in the near future. 

The Money Follows the Person (MFP) demonstration program, which was set to expire in fiscal year 2011, is extended through the Affordable Care Act for an additional five years.  The 13 States receiving awards today join the 29 States and the District of Columbia already operating MFP programs.  Together, these States will receive more than $45 million in the first year of the program, and more than $621 million through 2016. 

Many of the same goals under the MFP demonstration are shared and supported by the Community First Choice (CFC) Option, created by the Affordable Care Act. Today, nursing homes and institutions are too often the first or only choice for people with Medicaid who need long term care. The goal of this new option is to give States additional resources to make community living a first choice, and leave nursing homes and institutions as a fall back option.  Starting in October, this option will allow States to receive a six percent increase in federal matching funds for providing community-based attendant services and supports to people with Medicaid.  Over the next three years—through 2014—States could see a total of $3.7 billion in new funds to provide these services.  States currently receive Federal Medicaid matching funds for these activities at the State’s normal matching rate. 

To read the complete press release regarding this announcement, which includes a list of the 13 states that received funding, please go to http://www.hhs.gov/news/press/2011pres/02/20110222b.html   

Invitation to a Special Open Door Forum on HHS and HUD Community Living Partnership

You are invited to participate in a Special Open Door Forum sponsored by the U.S. Department of Health and Human Services (HHS) and the Department of Housing and Urban Development (HUD). This Special Open Door Forum will focus on understanding the HUD HHS Collaboration: creating sustainable partnerships between the housing and human service agencies at the federal, state & local levels to improve the availability of affordable and accessible housing, which is being accomplished through two major efforts:

HUD HHS Community Living Collaboration and its six initiatives

Linking long term services & supports with HUD’s new Category I & II vouchers to assist individuals with disabilities

This HHS and HUD Community Living Partnership Special Open Door Forum will take place on Tuesday, March 1, 2011, from 11:00 a.m. to 1:00 p.m. ET.  Following the presentation, the telephone lines will be opened to allow participants to ask questions of the subject matter experts from HUD and HHS, including CMS.

Presentation materials will be posted by Friday, February 25, 2011 to the HHS Office on Disability webpage at http://www.hhs.gov/od/

To participate in the Forum, please follow the instructions noted below.

1.  Dial 1-800-837-1935
2.  Give the Conference ID Number, 44280806

Note: TTY Communications Relay Services are available for the Hearing Impaired.  For TTY services dial 7-1-1 or 1-800-855-2880 and a Relay Communications Assistant will help.

An audio recording and transcript of this Special Forum will be posted to the Special Open Door Forum website at http://www.cms.gov/OpenDoorForums/05_ODF_SpecialODF.asp and will be accessible for downloading beginning on or around April 1, 2011.

For automatic emails of Open Door Forum schedule updates (E-Mailing list subscriptions) and to view Frequently Asked Questions please visit our website at http://www.cms.gov/opendoorforums/.

Information about the Community Living Initiative can be found at the HHS Office on Disability http://www.hhs.gov/od/topics/community/olmstead.html.

HHS Announces $750 Million Investment in Prevention

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New health care law provides new funding to reduce tobacco use, obesity and heart disease, and build healthier communities

Department of Health and Human Services Secretary Kathleen Sebelius today announced a $750 million investment in prevention and public health, funded through the Prevention and Public Health Fund created by the new health care law.  Building on $500 million in investments last year, these new dollars will help prevent tobacco use, obesity, heart disease, stroke, and cancer; increase immunizations; and empower individuals and communities with tools and resources for local prevention and health initiatives.

"Prevention is something that can't just happen in a doctor's office.  If we are to address the big health issues of our time, from physical inactivity to poor nutrition to tobacco use, it needs to happen in local communities," said Sebelius.  "This investment is going to build on the prevention work already under way to help make sure that we are working effectively across the federal government as well as with private groups and state and local governments to help Americans live longer, healthier lives."


The Prevention and Public Health Fund, part of the Affordable Care Act, is designed to expand and sustain the necessary capacity to prevent disease, detect it early, manage conditions before they become severe, and provide states and communities the resources they need to promote healthy living.  In FY2010, $500 million of the Prevention Fund was distributed to states and communities to boost prevention and public health efforts, improve health, enhance health care quality, and foster the next generation of primary health professionals.  Today, HHS posted new fact sheets detailing how that $500 million was allocated in every state. Those fact sheets are available at www.HealthCare.gov/news/factsheets/prevention02092011a.html. 

This year, building on the initial investment, new funds are dedicated to expanding on four critical priorities:

. Community Prevention ($298 million): These funds will be used to help promote health and wellness in local communities, including efforts to prevent and reduce tobacco use; improve nutrition and increase physical activity to prevent obesity; and coordinate and focus efforts to prevent chronic diseases like diabetes, heart disease, and cancer.

. Clinical Prevention ($182 million): These funds will help improve access to preventive care, including increasing awareness of the new prevention benefits provided under the new health care law.  They will also help increase availability and use of immunizations, and help integrate behavioral health services into primary care settings.

. Public Health Infrastructure ($137 million): These funds will help state and local health departments meet 21st century challenges, including investments in information technology and training for the public health workforce to enable detection and response to infectious disease outbreaks and other health threats.

. Research and Tracking ($133 million): These funds will help collect data to monitor the impact of the Affordable Care Act on the health of Americans and identify and disseminate evidence-based recommendations on important public health challenges. 

The Obama Administration recognizes the importance of a broad approach to addressing the health and well-being of our communities. Other initiatives put forth by the Obama Administration to promote prevention include:

. The President's Childhood Obesity Task Force and the First Lady's Let's Move! initiative aimed at combating childhood obesity.

. The American Recovery and Reinvestment Act of 2009 that provides $1 billion for community-based initiatives, tobacco cessation activities, chronic disease reduction programs, and efforts to reduce healthcare-acquired infections.

. The Affordable Care Act's National Prevention, Health Promotion and Public Health Council, composed of senior government officials, charged with designing a National Prevention and Health Promotion Strategy.

For more information about the FY2011 Prevention and Public Health Fund investments, visit www.HealthCare.gov/news/factsheets/prevention02092011b.html.

ONC announces launch of "Direct Project" pilots

The Office of the National Coordinator for Health IT (ONC) announced today that providers and public health agencies in Minnesota and Rhode Island began this month exchanging health information using specifications developed by the Direct Project, an 'open government' initiative that calls on cooperative efforts by organizations in the health care and information technology sectors.  Other Direct Project pilot programs will also be launched soon in New York, Connecticut, Tennessee, Texas, Oklahoma and California to demonstrate the effectiveness of the streamlined Direct Project approach, which supports information exchange for core elements of patient care and public health reporting. 

The launch of the pilot demonstrations, less than a year from the inception of the Direct Project, shows the project is on track to give U.S. health care providers early access to an easy-to-use, internet-based tool that can replace mail and fax transmissions of patient data with secure and efficient electronic health information exchange.

"This is an important milestone in our journey to achieve secure health information exchange, and it means that health care providers large and small will have an early option for electronic exchange of information supporting their most basic and frequently-needed uses," said Dr. David Blumenthal, national coordinator for health information technology.  "Other efforts are also going forward at full-throttle to build a comprehensive structure of health information exchange.  But by bringing together health care and IT companies, including competitors, to rapidly produce a system that supports basic clinical delivery and public health needs, we will be able to more quickly start building electronic information exchange into our health care system."

Designed as part of President Obama's 'open government' initiative to drive rapid innovation, the Direct Project last year brought together some 200 participants from more than 60 companies and other organizations.  The volunteers worked together to assemble consensus standards that support secure exchange of basic clinical information and public health data.  Now, pilot testing of information exchange based on Direct Project specifications is being carried out on schedule this year, aiming toward formal adoption of the standards and wide availability for providers by 2012.

"This is a new approach to public sector leadership, and it works," said Aneesh Chopra, the United States Chief Technology Officer.  "Instead of depending on a traditional top-down approach, stakeholders worked together to develop an open, standardized platform that dramatically lowers costs and barriers to secure health information exchange. The Direct Project is a great example of how government can work as a convener to catalyze new ideas and business models through collaboration."

The two pilot programs that have already begun using Direct Project-based information exchange are in Minnesota and Rhode Island:

Since mid-January, Hennepin County Medical Center (HCMC), Minnesota's premier Level 1 Adult and Pediatric Trauma Center, has been successfully sending immunization records to the Minnesota Department of Health (MDH). "This demonstrates the success that is possible through public-private collaborations," said James Golden, PhD, Minnesota's state HIT coordinator. "This is an important milestone for Minnesota and a key step toward the seamless electronic movement of information to improve care and public health." 

Recognizing Minnesota's leadership in delivering high-quality, cost-effective healthcare, U.S. Senator Amy Klobuchar (D-MN) said, "this is the type of innovation that can help strengthen our health care system by reducing waste and improving quality. We need to continue to improve our health care system by continuing to integrate information technology to better serve patients and providers."
The second pilot implementation site, The Rhode Island Quality Institute (RIQI), has delivered a pilot project with two primary goals. First, RIQI is improving patient care when patients are referred to specialists by demonstrating simple, direct provider-to-provider data. Second, RIQI is leveraging Direct Project messaging as a means to securely feed clinical information, with patient consent from practice-based EHRs to the state-wide HIE, currentcare, to improve quality by detecting gaps in care and making sure the full record is available to all care providers.

Discussing RIQI's collaborative approach to health IT, Laura Adams, president and CEO of RIQI said, "All too often, providers do not have the data they need to take the best care of patients they serve. Direct Project allows the Quality Institute to be on the cutting edge - providing health information exchange via currentcare, delivering the efficient rollout of technology through the Regional Extension Center, and enabling and measuring real patient outcome improvements in our Beacon Community. The ability to bring together and drive consensus among a diverse set of stakeholders has been critical in the successful rollout of these innovative programs."

"Rhode Island continues to be a nationwide leader in improving health care with better information technology," said Senator Sheldon Whitehouse (D-RI). "Health care providers communicating with each other in a secure and cost-efficient way helps patients get better sooner with less hassle and confusion."

Other pilot projects to be launched this year include a Tennessee effort with the Veteran's Administration, local hospitals and CareSpark to provide care to veterans and their families; a New York effort including clinicians in hospital and ambulatory care settings with MedAllies and EHR vendors; a Connecticut effort involving patients, hospitals, ambulatory care settings and a Federally Qualified Health Center with Medical Professional Services, a PHR, and a major reference laboratory; an expansion of the VisionShare immunization data pilot to Oklahoma; a California rural care effort involving patients, hospitals and ambulatory care settings with Redwood MedNet; and an effort in South Texas with a collaboration of hospitals, ambulatory care settings, public health, and community health organizations to improve care to mothers with gestational diabetes and their newborns.

The Direct Project was launched in March 2010 as a part of the Nationwide Health Information Network, to specify a simple, secure, scalable, standards-based way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the Internet in support of Stage 1 Meaningful Use requirements.  Participants include EHR and PHR vendors, medical organizations, systems integrators, integrated delivery networks, federal organizations, state and regional health information organizations, organizations that provide health information exchange capabilities, and health information technology consultants.

Information transfers supported by Direct Project specifications address core needs, including standardized exchange of laboratory results; physician-to-physician transfers of summary patient records; transmission of data from physicians to hospitals for patient admission; transmission of hospital discharge data back to physicians; and transmission of information to public health agencies.  In addition to representing most-needed information transfers for clinicians and hospitals, these information exchange capabilities will also support providers in meeting "meaningful use" objectives established last year by HHS, and will thus support providers in qualifying for Medicare and Medicaid incentive payments in their use of electronic health records.  The Direct Project specifications can also support physician-to-patient information transfers, and Microsoft Corp. today announced an application for that purpose based on Direct Project standards. For more information about the Direct Project, please visit http://directproject.org.

Other ongoing efforts supported by ONC are underway to bring about a comprehensive health information structure in the U.S.  These include technical and governance issues that are being addressed under the Nationwide Health Information Network, which embodies the standards, services and policies that enable health information exchange over the internet.  The Nationwide Health Information Network Exchange is already supporting some health information exchange between federal agencies and the private sector.  In addition, ONC provides grants to states to develop locally-appropriate policies and standards for health information exchange that are consonant with broader national standards.

For more information about the Office of the National Coordinator for Health Information Technology, please visit http://healthit.hhs.gov.


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Note: All HHS press releases, fact sheets and other press materials are available at http://www.hhs.gov/news.

Diet Guidelines Tweaked -- No Big Changes from MedPage Today

By John Gever, Senior Editor, MedPage Today

The federal government has issued the first update in five years of its "Dietary Guidelines for Americans" -- but despite broad recognition of the U.S. obesity crisis, the update left the major cornerstones of the guidelines largely intact.

The revision, a joint effort of the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services (HHS), was released today -- although it carries a 2010 date. USDA and HHS last updated the guidelines in 2005.
Full Article

HHS Increases Total LIHEAP Funding Available to Help Low-Income Families to $3.9 Billion

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U.S. Department of Health and Human Services Secretary Kathleen Sebelius recently announced the availability of additional funding to help eligible low-income families meet their home energy needs, bringing the total made available since October 1 to $3.9 billion.  These funds will go to states, tribes and territories under the Low Income Home Energy Assistance Program (LIHEAP) and are available under the terms of the latest continuing resolution. 

LIHEAP assists qualified families with their home energy needs such as heating in the winter, cooling their homes in the summer, and insulating their homes to make them more energy efficient and reduce their energy costs.

These block grant funds will supplement two previous releases of funds under continuing resolutions in Fiscal Year 2011.  A complete list of funds available to states today can be accessed at http://www.acf.hhs.gov/news/press/2011/liheap_allocation.html

Individuals interested in applying for energy assistance should contact their local/state LIHEAP agency.  For more information, please go to: http://www.acf.hhs.gov/programs/ocs/liheap/ or http://www.acf.hhs.gov/programs/ocs/liheap/brochure/brochure.html   

HUD and HHS Announce Joint Effort to Assist Persons with Disabilities to Move from Institutions to Independence

U.S. Housing and Urban Development (HUD) Secretary Shaun Donovan and Health and Human Services (HHS) Secretary Kathleen Sebelius announced today a joint partnership between the two agencies to help nearly 1,000 non-elderly Americans with disabilities leave nursing homes or other healthcare facilities to live independently.  This is the first time two federal agencies are offering a combination of rental assistance, health care and other supportive services targeted to this population.
     
HUD is providing $7.5 million in rental assistance vouchers that will help nearly 1,000 individuals with disabilities rent private apartments.  Public housing authorities in 15 states will administer the rental subsidies and will work with state human service agencies to identify eligible individuals who could benefit from the program.  For a local breakdown of the funding announced today, visit HUD's Web site. 
       
Individuals receiving rental assistance through the program will also receive health and social supports that will enable them to live independently.  These supports are provided through the HHS Centers for Medicare and Medicaid's "Money Follows the Person" (MFP) grant program, which allows individuals who qualify for Medicaid-funded nursing home or other institutional care to receive supports - such as in-home nursing and personal care services - while living in the community instead.  In places where the MFP program is not available, services will be provided by a state-sponsored institutional transitional program comparable to MFP that includes dedicated supportive services.
     
As part of President Obama's Year of Community Living initiative, HUD and HHS launched a joint effort to provide housing support for non-elderly persons with disabilities who are currently receiving long-term care in institutional settings.  The interagency collaboration is intended to allow persons with disabilities to live productive independent lives in their communities rather than in institutions. 

"The Obama administration is committed to helping Americans with disabilities live independent lives. Housing is a critical piece of the equation when it comes to transitioning out of institutions," said Donovan.  "Coordinating this effort with the Department of Health and Human Services is an important step in ensuring that more Americans with disabilities will have the housing and support they need to fully participate in community life." 

"Through our collaboration with the Department of Housing and Urban Development, I know that we will be able to dramatically change peoples' lives," said Sebelius.  "Individuals with disabilities can have a life in the community that serves their needs and supports them in leading productive, meaningful lives."
     
The funding announced today is being provided through HUD's Rental Assistance for Non-Elderly Persons with Disabilities Program.  It is part of the $40 million HUD made available April 2010 to public housing authorities across the U.S. to fund approximately 5,300 rental assistance vouchers for non-elderly persons with disabilities to promote independent living for this community.  Public housing authorities applied for funding under two categories. 
     
Last October, HUD awarded $33 million to support a first round of 4,300 vouchers, making it possible for non-elderly individuals with disabilities and their families to access affordable housing in communities that meet their housing needs and so avoid potential institutionalization.  Today's announcement is for the second round funding to provide 948 vouchers targeted for non-elderly individuals with disabilities currently living in institutional settings, such as nursing homes, but who could move into a community with assistance. 

These vouchers will augment work already being done by HHS' Centers for Medicare & Medicaid Services (CMS) through its Money Follows the Person (MFP) rebalancing demonstration program.  Now in its fourth year, the MFP program has made it possible for almost 12,000 individuals to live more independent lives by providing necessary supports and services in the community.  Twenty-nine states and the District of Columbia are currently participating in the MFP program and CMS is expecting a new round of grant applications on January 7th.
     
State Medicaid agencies and local human service organizations will link eligible families to local public housing authorities that will administer voucher distribution.  To improve the connections between the housing authorities and Medicaid agencies, HUD and HHS have launched the Housing Capacity Building Initiative for Community Living Project to assist seniors and individuals with chronic conditions who are at risk of institutionalization or who currently receive care in institutional settings, in finding appropriate housing in order to live more independent lives.   
     
The Community Living Initiative is an outgrowth of the 1999 landmark Supreme Court ruling in Olmstead v. L.C.  In that case, the Court ruled that the Americans with Disabilities Act (ADA) protects a person with a disability from being unnecessarily institutionalized.  The Court said that such forced institutionalization can lead to isolation and segregation of individuals with disabilities and be a serious and pervasive form of discrimination.

ACOs and the Enforcement of Fraud, Abuse, and Antitrust Laws | Health Policy and Reform

by Robert F. Leibenluft, J.D.

Hospitals and physicians are eagerly awaiting regulations for accountable care organizations (ACOs), which many observers view as the best hope provided by the Patient Protection and Affordable Care Act (ACA) for needed delivery system reform. Starting in 2012, health care providers in ACOs that furnish efficient, high-quality care to Medicare patients will share in Medicare’s savings. Providers are concerned, however, that in creating ACOs they risk violating fraud, abuse, and antitrust laws.¹ To address these fears, the Department of Health and Human Services (DHHS), the Federal Trade Commission, and the Department of Justice, under the direction of the White House, are collaborating to provide waivers, safety zones, and guidance to providers.

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Assessing an ACO Prototype — Medicare’s Physician Group Practice Demonstration | Health Policy and Reform

by John K. Iglehart

One of the few major provisions of the Affordable Care Act (ACA) with solid bipartisan support establishes a new delivery model: the accountable care organization (ACO). Congress directed the Department of Health and Human Services (DHHS) to develop an ACO program to improve the quality of care provided to Medicare beneficiaries and reduce its costs while retaining fee-for-service payment. Under this program, medical groups would have to take responsibility for achieving these goals and would share in any savings derived by Medicare.

Despite the burst of interest in ACOs, little attention has been paid to the results of a demonstration project sponsored by the Centers for Medicare and Medicaid Services (CMS) that was the model for the reform law’s ACO provisions. In the Medicare Physician Group Practice (PGP) demonstration, the CMS contracted with 10 large multispecialty groups with diverse organizational structures, including free-standing physician groups, academic faculty practices, integrated delivery systems, and a network of small physician practices.¹

As a share of total Medicare spending, fee-for-service expenditures for physician services have been relatively stable (13% of $491 billion in 2009). However, this payment model has been under attack because of its inherent incentive for increasing the quantity, but not necessarily the quality, of physician-delivered care. But policymakers vividly remember the backlash against managed care, whose capitation payments were seen as an incentive to stint on care, so with no new alternative to fee for service in the offing, Medicare’s physician-payment policy has remained essentially static.²

In 2000, Congress tasked the DHHS with testing incentive-based payment methods for physicians, directing Medicare to encourage care coordination and investment in processes for more efficient service delivery and to reward physicians for improving health care outcomes. In response, the CMS designed the PGP project to examine whether care management initiatives could generate cost savings by reducing avoidable hospital admissions, readmissions, and emergency department visits, while improving quality.¹
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Questionable Billing by Skilled Nursing Facilities

Image via WikipediaThe Department of Health and Human Services' Office of Inspector General has released the following report: Questionable Billing by Skilled Nursing Facilities (OEI-02-09-00202) http://go.usa.gov/rCy

Skilled nursing facilities (SNF) categorize beneficiaries into resource utilization groups (RUG) based on their care and resource needs. Medicare generally pays the most for ultra high therapy RUGs. Medicare also pays more for RUGs for beneficiaries who require more assistance with certain activities of daily living, such as eating.

The OIG found that SNFs increasingly billed Medicare for higher paying RUGs from 2006 to 2008, even though beneficiary characteristics remained largely unchanged. Specifically, they found large increases in RUGs for ultra high therapy, with payments to SNFs for ultra high therapy increasing by nearly 90 percent from 2006 to 2008, rising from $5.7 billion to $10.7 billion. In addition, RUGs for high levels of assistance with daily activities increased. The investigators  also found that for-profit SNFs were far more likely than nonprofit or government SNFs to bill for higher paying RUGs, and that a number of SNFs had questionable billing in 2008. Taken together, these findings raise concerns about the potentially inappropriate use of higher paying RUGs, particularly those for ultra high therapy.

HHS PRESS RELEASE: New Affordable Care Act rules shed light on high health insurance rate hikes

Image via WikipediaNew Affordable Care Act rules shed light on high health insurance rate hikes

New proposed Affordable Care Act regulations announced today by the U.S. Department of Health and Human Services (HHS) will bring new transparency and scrutiny to proposed health insurance rate increases.  These proposed rules allow HHS to work with states to require insurers to publicly disclose and justify unreasonable rate increases.

“Year after year, insurance company profits soar, while Americans pay more for less health care coverage,” said Secretary Sebelius. “The Affordable Care Act is bringing unprecedented transparency and oversight to insurance premiums to help reign in the kind of excessive and unreasonable rate increases that have made insurance unaffordable for so many families.”

Health insurance premiums have risen rapidly over the past decade, straining pocketbooks for American families and businesses.  Since 1999, average premiums for family coverage have risen 131 percent. 

The Affordable Care Act has already begun to help states strengthen or create rate review processes.  On August 16, HHS awarded $46 million to 45 states and the District of Columbia to help them improve their oversight of proposed health insurance rate increases. This is part of $250 million that the health reform law makes available to states to take action against insurers seeking unreasonable rate hikes.

Today’s proposed regulations will build on these efforts by requiring insurers in all states to publicly justify any unreasonable rate increases beginning in 2011. In 2011, proposed rate increases of 10 percent or higher will be publicly disclosed and thoroughly reviewed to determine if the rate increase is unreasonable.  After 2011, state-specific thresholds would be set using data and trends that better reflect cost trends particular to each state.  Insurance company’s justifications for unreasonable increases will be posted on HealthCare.gov and the insurance plan’s website.

“The proposed rate review policy will empower consumers, promote competition, encourage insurers to do more to control health care costs and discourage insurers from charging premiums which are unjustified,” said Jay Angoff, director of HHS’ Office of Consumer Information and Insurance Oversight.

Under the proposed regulation, states with effective rate review systems would conduct the reviews. If a state lacks the resources or authority to do thorough actuarial reviews, HHS would conduct them.  Meanwhile, HHS will continue to make resources available to states to strengthen their rate review processes. 

In 2014, the Affordable Care Act empowers states to exclude health plans that show a pattern of excessive or unjustified premium increases from the new health insurance exchanges.

For more information on the regulation, go to: http://www.healthcare.gov/news/factsheets/ratereview.html.  For links to the regulation or other premium review information, go to: www.hhs.gov/ociio/initiative/index.html.

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The New Health Care Law and Dental Coverage - AARP Bulletin

by: Susan Jaffe

No. The law doesn't require insurers to cover dental care for adults, but there's a good chance that could change when the state insurance exchanges begin operating in 2014. These exchanges will be online marketplaces where consumers can easily compare prices and coverage and find the policy that best fits their needs.

The law says that health insurance plans sold on an exchange have to cover an "essential health benefits" package similar to the typical employer-sponsored health care policy. Nearly half of the employers offering health benefits to their employees this year provide some kind of dental coverage, including 87 percent of employers with 200 or more workers, according to a recent survey.

Although adult dental care is not among some examples of benefits the law says must be covered, consumer advocates say it appears that the U.S. Department of Health and Human Services could include it in the regulations that will detail what essential benefits must be provided.

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New Affordable Care Act Grants to Help Put Patients in Control of their Healthcare

Image via WikipediaThe U.S. Department of Health and Human Services (HHS) today announced new Consumer Assistance Grants program awards of nearly $30 million to help states and territories put patients in charge of their health care. These grants will support states' efforts to establish or strengthen consumer assistance programs that provide direct services to consumers with questions or concerns regarding their health insurance.
"The Affordable Care Act's Patient's Bill of Rights gives people important benefits and ends the worst insurance company abuses," said Secretary Kathleen Sebelius. "These grants will help ensure consumers' rights are protected, and they are another way the new law is putting patients, not insurance companies, in charge of their health care."

These new grants will allow states, who are in some cases partnering with local non-profits, to help strengthen and enhance ongoing efforts in the states and local communities to protect consumers from some of the worst insurance industry practices. Altogether, 35 states, four territories and the District of Columbia applied for and will receive grant awards.

The grants will build on other programs and initiatives recently announced by HHS to help consumers make decisions about their care, including www.HealthCare.gov, where consumers already can find health insurance options customized to their needs and location as well as other information about their benefits and rights under the Affordable Care Act. State consumer assistance programs also will help consumers act on their new right to appeal if their insurance plan denies them coverage. Specifically, these grants will:

* Help consumers enroll in health coverage;
* Help consumers file complaints and appeals against health plans;
* Educate consumers about their rights and empower them to take action; and
* Track consumer complaints to help identify problems and strengthen enforcement.

A fact sheet and summary of how each state or territory will use the new resources can be found at http://www.healthcare.gov/news/factsheets/cap_grants.html 

Consumer Assistance Grants have the potential to benefit millions of Americans. These grants will fund programs that will support consumers both now as we transition to a more competitive, patient-centered health insurance marketplace in 2014 and once that new marketplace is established.

Primary care physician training expanded with $167 million HHS grant... American Medical News

Image via WikipediaBy Chris Silva, amednews staff
More than 80 accredited primary care residency programs will be able to increase the number of doctors they help train, thanks to a $167.3 million grant from the Dept. of Health and Human Services.

By 2015, the money will help create 889 primary care residencies in general pediatrics, general internal medicine and family medicine.

The grant is part of $320 million in awards that HHS announced on Sept. 27. The funding, which will strengthen the primary care work force, was made available through the health system reform law.

"Chronic diseases, most of which are preventable, are one of the main reasons health care costs have soared over the past several decades," HHS Secretary Kathleen Sebelius said. "Investing in our primary care work force will strengthen the role that wellness and prevention play in our health care system. With these grants, Americans from all backgrounds will have new opportunities to enter the health care work force."
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