Posts Tagged ‘centers for medicare & medicaid services’

April 9, 2010

ACOs: The New Kid to Watch With Health Reform

It’s time to remember ACOs, the latest acronym on many lips in Washington and included in the recently passed health reform legislation.  The idea—reward providers for bringing high level quality and cost-efficient, coordinated care to communities.  ACOs are envisioned as community-based entities accountable for comprehensive healthcare services.  They’re supposed to promote accountability and develop patterns of practice considered to be the best and most effective.  Additional Medicare payments will be given to those groups of providers that work together to manage and coordinate care for Medicare beneficiaries—of course, if they can show that they  met certain quality criteria, achieve specified cost savings, and meet structural requirements for reporting and governance (to be outlined by the Centers for Medicare & Medicaid Services (CMS).

 You’ll find ACOs under section 3022 of the new Patient Protection and Affordable Care Act (that’s the PPACA), which calls for the establishment of the ACO program no later than January 1, 2012. The Secretary of the Department of Health and Human Services  will determine the policies and procedures that will apply to ACOs. 
 Who’s eligible?   An ACO may be formed by a wide range of professionals, including physicians in group practice arrangements, networks of individual physician practices, hospitals, and partnerships or joint ventures between hospitals and physician groups, that are willing to be held to the accountability standards. 

Among the qualifications: Providers must agree to participate in the program for at least three years  and they have to have the HHS Secretary assign it at least 5,000 Medicare beneficiaries and include a sufficient number of primary care physicians for serving those patients.  The Secretary can give preferences to  ACOs that participate in similar arrangements with private third party payers.

The ACO is not a new idea, but rather builds on ideas and models (from Mayo to Kaiser health) that have been discussed for years. Cost savings and quality improvement are key.  How that will be achieved, measured, and evaluated is still open to question, with critics noting this could be managed care in disguise.  And if the patients sense a “warmed over” product focused on cost-savings, the hopes for real success could be dimmed. The division of savings could make some family physicians uncomfortable with ACOs, according to the American Academy of Family Physicians. As the degree of risk borne by ACOs increases, the need for regulation of the financial security of these organizations will also increase, which could influence patient care decision making. Financing and regulatory policies will still continue to create pressures in ways that may take the focus off the patient.

But that gets to the cost issues again.  If the focus is on how to best coordinate the care of Medicare beneficiaries—and they may mean more connections rather than less connections to a host of other providers and community and social service agencies than envisioned in this plan. Whether this will be a successful evolution—or revolution—remains to be seen.

Tags: , , , , , , , , , ,
Posted in Health Reform, Patient Protection and Affordable Care Act, Policy, health insurance | 1 Comment »

November 19, 2009

Mammogram Payment Leads to Empty Seat at CMS

The brouhaha about breast cancer screening is raising major concerns about who should get mammograms.  It is also heightening anxiety about whether mammograms will be paid for by Medicare and private  insurers.  Which leads me to the  Centers for Medicare & Medicaid Services (CMS), the government agency charged with responsibilities for health care  payments.  CMS, the agency with control over Medicare and Medicai,  is still leaderless even though more than a year has passed since President Obama took office. 

Secretary Sebelius, as secretary of Health and Human Services (HHS), presides over this agency and knows something about payments to insurers, having been an insurance commissioner back in Kansas.  With that background, she should know how critical CMS is to the functioning of the health care system. It is troubling that Secretary Sebelius has not taken action to fill what is the perhaps the most significant and essential slot in HHS.  At this critical juncture, there is no leadership in place to assess the structure and resources of CMS that will have the massive task of implementing any health reform legislation. 

Of great importance to academic health centers,  the Administration has not taken action on some of the most pressing issues for Medicare beneficiaries, which fall under the purview of CMS, specifically  participation of Medicare beneficiaries in clinical trials.  The current clinical trials policy hampers such participation.  In fact, the clinical trial policy threatens the nation’s ability to conduct clinical research and compete globally?  Secretary Sebelius and Mr. Sunstein, our new regulatory czar in the White House, have been made aware of the future dangers but have taken no action.   Why is CMS not an issue?  

Waiting for health reform is no answer.  The problems with CMS organization, resources, and policies will only be heightened.  Action must be taken now.  Nominating and appointing someone to head this agency is critical.

Tags: , , , , , , , ,
Posted in Health Reform, Policy, clinical trial policy, research | No Comments »

August 18, 2009

A Real Health Reform Issue to Address: Medicare’s Clinical Trial Policy

Let’s get some real issues on the table in the health reform debate—like Medicare’s clinical trial policy.  The Medicare program is not only the key to current and future health care delivery in this nation but also the most critical link to all clinical research occurring throughout the nation. 

Good science—and new cures and treatments for a host of diseases and illnesses–require that Medicare beneficiaries participate in clinical trials.  That was the vision and purpose of the clinical trial policy, laid out in an executive memorandum signed by President Clinton in 2000.  The goal was to provide increased access for Medicare beneficiaries to clinical trials—and that is not happening. During the Bush Administration, the policy was not fulfilling its intent and, in fact, was quite dismantled, creating a situation that discouraged participation of seniors in trials.

It’s not only seniors. The President had better check his health plan because many of the government plans do not cover clinical trials—as they should. 

Health and Human Services Secretary Sebelius should be spending more time addressing this issue.  She can provide the leadership to reform Medicare’s clinical trial policy, which currently:

  • Compromises the quality and credibility of many research studies by discouraging enrollment of elderly patients
  • Limits coverage for the elderly to potentially life-saving therapies and treatments
  • Undermines the financial viability of the nation’s academic health centers where the majority of clinical trials take place
  • Increases the likelihood of an adverse impact on the nation’s economy and job market as clinical trials continue to move overseas.

The Association of Academic Health Centers (AAHC) has been at the forefront in calling for reform of the policy.  One of AAHC’s most important recommendations is for the HHS Secretary to establish the position of research coordinator at the Centers for Medicare & Medicaid Services (CMS) to oversee clinical research coverage policy.  This position would ensure that an expert with knowledge of clinical research and trials processes and operations is providing needed leadership and making the issue a national priority.

President Obama and Secretary Sebelius need to signal that they recognize the significance of Medicare’s clinical trial policy.  Appointing a permanent administrator for CMS would also be a good start.  If the Administration can’t address clinical  trial policy, there are  many on Capitol Hill who will check their health plans, suddenly wake up and take notice, and address Medicare’s clinical trial policy so they can claim some real progress on health care reform.

Tags: , , , , ,
Posted in Health Reform, clinical trial policy | No Comments »

July 16, 2009

SOS on Regulatory Reform in Health Reform

I read that countless numbers of people are worried about being regulated by government in any reformed health system.   But no one, especially policymakers, seems to be addressing the regulatory infrastructure and the costs of regulation, which might open up a pandora’s box and really shed light on the extent to which the public is benefiting from the regulations developed to protect the American people (which is an issue for a longer discussion).  No one is asking whether the agencies mandated to regulate, including the Centers for Medicare & Medicaid Services,  have the resources to address implementation and enforcement of current and new regulations.  Policymakers should be addressing those resources now.  Policymakers would also do well to look at the costs of compliance for the government and for health care providers.   A 2005 study by the Association of Academic Health Centers  found that the costs of compliance  increased up to 300% in the previous decade and often more than 70% a year at academic health centers throughout the nation. We are hearing of even greater increases at the present time.  No one is denying the need for accountability and protecting quality, safety, and privacy in the health care arena.  But it may be time for the government to ask about the costs and benefits of regulation along with addressing the need for rational and ”smart” regulations.  There is also an urgent need for harmonization within the regulatory environment.  Interagency task forces have done little to ensure there is no contradiction and confusion between regulations coming out of the many government agencies.  If we really want to ensure safety and quality for the public as well as savings in health care delivery, reform of the regulatory world must be addressed now. 

Tags: , , , , , , , ,
Posted in Health Reform, Policy | No Comments »