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Innovation by Ambulance

Medicare wants to change how it pays for emergency ambulance services to give seniors more options besides going to a hospital emergency department, according to officials at HHS, Health and Humans Services, the federal agency the oversees CMS, the Centers for Medicare and Medicaid.

“Other options could include going to an urgent care center, a doctor’s office, or even treatment at home under supervision of a doctor via telehealth links

“It’s just a pilot project for now, but if adopted nationwide the idea could save Medicare more than $500 million a year and allow local fire departments and ambulance services to focus the time and energy of first responders on the most serious emergencies…

“Unveiling the ambulance proposal at a Washington, D.C., fire station, Adam Boehler, the innovation center director, said he was astounded to learn that under current rules Medicare will only pay for emergency ambulance services if the patient is going to a hospital, in most cases.

“‘I thought that was a joke,’ said Boehler, a former health care entrepreneur who ran a company providing in-home medical care to seriously ill patients. He called Medicare’s current policy a “ridiculous incentive” to funnel patients to the most high-cost setting. Most private insurance plans discourage emergency room use by imposing higher copays, and some state Medicaid plans are trying similar tactics.

“Appearing at the same event, the chief medical officer for the New York City fire department endorsed Medicare’s experiment. Dr. David Prezant said his agency is overwhelmed with non-emergency calls and transporting patients to a hospital is a time-consuming process that keeps ambulance crews needlessly tied up.

“‘If only 20 percent of our calls no longer required transport to an ED (emergency department), we would save lives in cases when every second counts,’ Prezant said. Associated Press.

Drug Coverage Proposal

Improvements in the cost of medications for Medicare-eligible customers may not be too far off. The Centers for Medicare and Medicaid (CMS) has proposed some new ways to lower drug costs for those in the Medicare program, and with drug coverage through a stand-alone prescription drug plan or with a Medicare Advantage plan that includes drug coverage.

One provision in the proposal targets e-prescribing and would require the person’s plan “to adopt a provider Real Time Benefit Tool by the start of 2020.

“‘RTBTs have the capability to inform prescribers when lower-cost alternative therapies are available under the beneficiary’s prescription drug benefit, which can improve medication adherence, lower prescription drug costs, and minimize beneficiary out-of-pocket costs,’ CMS stated.

Another provision of the CMS proposal is that drug coverage Explanations Of Benefits (EOBs) that people receive from their plans will be tasked with including drug pricing information and lower cost therapeutic alternatives as part of these EOBs to give customers the information in hand that can also potentially help them lower their out-of-pocket costs for their particular medications.

This is not a comprehensive list of the provisions of the CMS proposal which could become a set of new rules in the near future. However, we do want to get info about these two particular provisions out there, so everyone can have confidence in any changes to come and know there will be tangible things for American households coming that can help lower their drug costs.

Source: Kyle Murphy, “HealthPayer Intelligence.”

New Hospital Rule in 2019

The hospital price transparency rule takes effect on January 1, requiring providers to publicize their rates for all items and services.

“Starting January 1, 2019, hospitals will be required to post their price lists online in an effort to increase price transparency and empower consumers to make informed choices about their care.

“The mandate stems from the 2019 inpatient and long-term care hospital prospective payment system (IPPS/LTCH PPS) final rule, released in August, in which CMS included the requirement for hospitals to update their public price lists at least annually.

“‘The policies in the IPPS/LTCH PPS final rule further advance the agency’s priority of creating a patient-centered healthcare system by achieving greater price transparency, interoperability, and significant burden reduction so that hospitals can operate with better flexibility and patients have what they need to be active healthcare consumers,’ CMS wrote…

“While hospitals can choose the format for presenting the data, as long as it’s machine-readable, the list must include all items and services provided by the facility, CMS stated.

“‘CMS encourages hospitals to undertake efforts to engage in consumer friendly communication of their charges to help patients understand what their potential financial liability might be for services they obtain at the hospital, and to enable patients to compare charges for similar services across hospitals,’ the agency said.”

Source: Jennifer Bresnick, “HealthPayer Intelligence”

Winter Workouts

Cold comfort

“In some ways, winter can offer benefits you don’t get in summer. For instance, cold weather may actually improve endurance, says Dr. Tenforde. “In colder temperatures your heart doesn’t have to work as hard, you sweat less, and expend less energy, all of which means you can exercise more efficiently.”

“Studies also have shown that exercising in cold weather can transform white fat, specifically belly and thigh fat, into calorie-burning brown fat.

“Plus, winter workouts help you get exposure to sunlight, which may help ward off seasonal affective disorder, a type of depression that some people experience during the winter months. While cold-weather exercise is safe for most people, if you have certain conditions, such as asthma or heart problems, check with your doctor to review any special precautions you need to take based on your condition or medications.” Source: Harvard Health Publishing. For more information Click Here.

Tech Tackles Alzheimers

“The foundering search for an Alzheimer’s cure is fueling a parallel quest by technology companies to help patients and caregivers cope with the disease. The quest is to help patients and family caregivers cope with the disease by using virtual reality software, robotics, and novel communication tools. The solution is not simply developing tools to manage patient symptoms, but to deliver better support to family caregivers who are collectively spending more than $500 billion annually to care for elderly relatives.

“‘If we do not support the role of family caregivers and value them in this process, there is nothing we can do to bend the cost curve beyond what we’re doing,’ said Thomas Riley, chief executive of Seniorlink, which developed a digital communication platform to help coordinate care for Alzheimer’s patients.

“Technology firms are also selling digital products to help patients: A company called Dthera Sciences has built a therapy that uses music and images to help patients recover memories. The product analyzes facial expressions to monitor the emotional impact on patients and discover the sounds and visuals that provide the greatest relief.

“Another firm, Ageless Innovation, has developed robotic cats and dogs that help to treat the depression and social isolation that so often afflicts people with Alzheimer’s. Ted Fischer, the company’s CEO, said Wednesday that research conducted by Pace University showed the products resulted in better patient outcomes across several measures, including a reduction in hospitalizations. “And it produces joy and meaningful connections for these patients,” Fischer said.

“The pharmaceutical industry has racked up a long list of failures in recent years, with many drug candidates following a similar narrative. A promising treatment in early-stage research turns out to be a flop in late-stage trials, putting investors, patients, and caregivers on a roller coaster that always ends in disappointment and a return to the drawing board.

“Fischer and other technology executives (have) said their products are neither panaceas nor substitutes for a hoped-for pharmaceutical breakthrough that could reverse or prevent the symptoms of the disease. But they also urged public and private funders to step up investments in technology solutions that, in the short term, represent the best option for patients and families.”

Source: STAT.


New Hampshire is Next!

“The CMS on Monday, May 7th, gave New Hampshire the green light to impose work rules for some adult Medicaid recipients. It’s the fourth state to win approval for that requirement.

“The state’s Medicaid 1115 waiver will require adult beneficiaries between the ages of 19 and 64 to participate in 100 hours of “community engagement activities” a month to maintain eligibility for coverage. Community engagement is defined as having a job, being enrolled in school, participating in job skills training, or performing some sort of community service.

“‘Today’s announcement by the CMS … is a transformative step towards a more thriving workforce,’ Gov. Chris Sununu said in a written statement. ‘Work requirements help lift able-bodied individuals out of poverty by empowering them with the dignity of work and self-reliability while also allowing states to control the costs of their Medicaid programs—we are committed to helping more people get into the workforce, as it is critical not only for individuals but also for our economy as a whole.'”
Source: Steven Ross Johnson, Modern Healthcare.

CMS Encourages Innovation!

On Monday April 9, 2018 the Centers for Medicare and Medicaid finalized the rule that “eliminates (Affordable Care Act) standardized options starting in 2019 to encourage innovative plan designs among insurers.”

This is a good move for the coming years in the, non-Medicare, individual/family health insurance markets of America!  This change indicates that our current government recognizes that health insurance plans are not a one-size-fits-all financial product.  We have been saying this all along and CMS Director Verma has now been quoted saying as much- and we are thankful.

At this time it is unclear if ACA-compliant plans this fall, for the 2019 calendar year, will reflect this change in standardization requirements, and make health insurance plans more reflective of the coverage needs of the people in each state.  However, since the standardization requirements are eliminated in 2019- we do expect the individual/family plans, for the 2020 calendar year, to be more fitted to each state.

As everyone anticipates smart changes coming in the years ahead to the individual/family health insurance market we should be aware that according to Director Verma, the states are still subject to the ACA requirement that insurers offer 10 essential health benefits.  Although the standardization requirements are eliminated, this doesn’t mean states can allow ACA-compliant plans to exclude maternity care or mental health benefits.

We do expect to have more appropriate premiums and coverage choices for individuals and families in the coming years.  All in all, a good day.

Reference: Shelby Livingston and Susannah Luthi, Modern Healthcare.

New to Medicare: Some DNA Tests

“The CMS announced Friday that it will cover diagnostic laboratory tests using gene sequencing technology for Medicare cancer patients.

“The CMS said the tests — called next generation sequencing — can help patients and their oncologists make better treatment decisions as well as help more patients enroll in clinical trials. Patients with recurrent, metastatic, relapsed, refractory or stages III or IV cancers will be eligible to get the tests covered under Medicare, according to the agency.

“‘We want cancer patients to have enhanced access and expanded coverage when it comes to innovative diagnostics that can help them in new and better ways,’ said CMS Administrator Seema Verma in a statement. ‘That is why we are establishing clear pathways to coverage, while at the same time supporting laboratories that currently furnish tests to the people we serve.’

“The CMS’ decision to cover such tests comes shortly after the FDA’s recent approval of Foundation Medicine’s genomic profiling test called FoundationOne CDx. The CMS worked with the FDA to review the effectiveness of the test.” Source: Maria Castellucci, Modern Healthcare.

Changes in Cardiac Device Coverage

CMS, the Centers for Medicare and Medicaid, has finalized its changes to its Medicare coverage of implantable cardiac devices, which should reduce the wait-times required to get the implantation procedure done and cut the regulatory burden for providers that use the devices for their patients.

This “is the first major change to Medicare’s implantable cardioverter defibrillator, or ICD, coverage in more than a decade. The CMS wants to reduce some of the barriers to care outlined in its most recent coverage determination, issued in 2005.

“The CMS is eliminating waiting periods for device implantation and dropping a policy that requires patients to be tracked in a registry.”

“It is also requiring shared decision-making, which the agency said would empower patients…

“The agency is also looking to hasten access to ICDs by allowing patients with an existing ICD who suffer a heart attack or undergo a coronary revascularization procedure to obtain a replacement device without waiting. Previously, the devices could not be implanted within 40 days of a heart attack or 90 days of bypass surgery or angioplasty…

“ICDs have been used since the 1980s, and the CMS began covering them in 1986. Initially, they were mostly used in patients with recurrent cardiac arrest who were not responsive to drug treatments. In 2005, the agency finalized coverage for primary prevention of arrhythmia.

“The devices are wired to the heart and deliver an electric shock if they detect an abnormal rhythm. They are a significant revenue driver for hospitals. It’s estimated that 10,000 ICDs are implanted every month, and the average hospital stay after placement is eight days. That generates an average of $12,423 in hospitalization costs per patient.”
Source: Virgil Dickson, Modern Healthcare.

Kentucky Leads the Way!

“Kentucky has become the first state in the nation to receive federal approval to impose work requirements as a condition of Medicaid coverage.

“Nine other states—Arizona, Arkansas, Indiana, Kansas, Maine, New Hampshire, North Carolina, Utah and Wisconsin—have also applied for the Section 1115 waivers.

“In the coming weeks, adult beneficiaries in Kentucky between 19 to 64 will be required to complete 80 hours per month of community engagement activities, such as employment, education, job skills training, and community service to maintain their Medicaid eligibility.

“Former foster-care youth, pregnant women, primary caregivers of a dependent, beneficiaries considered medically frail and full-time students are exempt from the new requirements.

“Kentucky will lock beneficiaries out of coverage for noncompliance. A person’s coverage can only be reactivated on the first day of the month after they complete 80 hours of community engagement in a 30-day period.

“If a suspended beneficiary hasn’t met the work or volunteering requirement by their redetermination date, their Medicaid enrollment will be terminated and they will have to submit a new application to rejoin Medicaid.

“The CMS also approved Kentucky’s request to impose premiums on expansion beneficiaries and parents and other family caretakers in the state.

“Non-payment over a 60-day period will result in a six-month lockout from coverage.

“Enrollees will also lose coverage if they don’t report income changes quickly.

“The approval also allows Kentucky to end retroactive coverage for Medicaid beneficiaries.

“The new waiver nixes providers’ ability to bill for services provided in the three months before the application, assuming the patient was eligible during that time.

“Finally, Kentucky has gained permission to continue not covering non-emergency transportation services.

“As of October 2017, Kentucky has more than 1.2 million people in Medicaid and the Children’s Health Insurance Program, a net increase of 108% since Medicaid expansion under the ACA, according to the CMS.”
Source: Virgil Dickson, Modern Healthcare.