An Overview of the Hospital Value-Based Purchasing Program0

Section 3001(a) of the Affordable Care Act (ACA) includes a new section 1886(o) to the Social Security Act and amended 42 U.S.C. § 1395ww to establish the hospital value-based purchasing (VBP) Program.

Under the VBP Program, beginning October 2012 hospitals will face a 1% reduction overall on Medicare payments under the Inpatient Prospective Payment System (IPPS), as these funds will be used to pay for the performance bonuses under VBP Program. By 2015, hospitals that continue to show poor performance ratings will not only be excluded from the bonus pool, they will also face additional cuts in reimbursement. … Read more →

Administrative, Children's Health, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Non Clinical, Regulatory, Technology

Understanding the Minimum Medical Loss Ratio0

Under the Affordable Care Act (ACA), in 2012 consumers anticipate the return of an estimated $1 billion in rebates from health insurance issuers (issuers).

Commonly referred to as the “80/20 provision” of the ACA, the regulations governing Medical Loss Ratio (MLR) rebates appear in Title 45 of the Code of Federal Regulations, Part 158. The minimum MLR (45 C.F.R. § 158.210) applies as follows:

  • Large group market:  For all policies issued in this market during the MLR reporting year, an issuer must provide a rebate to enrollees if the issuer has an MLR of less than 85% (subject to adjustments as discussed below).
  • Small group market and individual market:  For all policies issued in these markets during the MLR reporting year, an issuer must provide a rebate to enrollees if the issuer has an MLR of less than 80% (also subject to certain adjustments).

States, however, retain the option to set a higher MLR, provided the State ensures adequate participation by health insurance issuers, competition in that State’s health insurance market, and value for consumers to ensure that premiums are used for clinical services and quality improvements.  (45 C.F.R. § 158.211.)

While there are specific requirements relating to the aggregation of data in calculating an issuer’s MLR (45 C.F.R. § 158.220), generally an issuer’s MLR is: The ratio of the issuer’s incurred claims plus the issuer’s expenditures for activities that improve health care quality (the numerator) to the issuer’s premium revenue, less any Federal and State taxes as well as licensing and regulatory fees (the denominator). … Read more →

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The War on Health Care0

This article first appeared in the Daily Journal on June 15, 2012.

Throughout history, America’s methods of providing health care have always had an understated yet powerful impact on the way she chooses to wage war.  And yet, this may be the first time that health care is itself under siege. Indeed, the specter of war has provided countless opportunities to test society’s mettle in battle, while forcing those in power to prioritize in terms of their country’s health care. As sides are drawn and campaigns evolve, the strategies of combat take shape in ways previously unforeseen. This is certainly true in contemporary America, though in our modern age of reform it is health care itself that has come under attack.

Medically speaking, advances in science, technology and the provision of health care have commandeered the new millennium, both in practice and politics. And yet, medicine’s inestimable progress since the Civil War is often largely taken for granted by both the decision makers and the recipients of a country that has come to expect state-of-the-art facilities and easy access to providers. A century and a half ago, the delivery of medicine was grossly misunderstood, frequently useless and often barbaric. “Civil War surgeons cleaned their instruments by periodically rinsing them with water, usually at the end of the day. . . . Typically, the operator wiped the blood and other material from his knife with a quick swipe across the front of his large apron, which was usually stained with blood and pus from prior sessions.”[1]

Such an abysmal depiction of health care in the middle of the nineteenth century serves to underscore the catastrophic losses endured by both North and South in the deadliest conflict on American soil, while highlighting the need for a potent, reliable and inclusive health care structure on which to rely.. Dr. Jonathan Letterman, Civil War medical director of the Army of the Potomac, offered a wise analogy describing the relationship between the science of medicine and our ability to deliver it:  “Without proper means, the Medical Department can no more take care of the wounded than the army can fight a battle without ammunition.”[2] … Read more →

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Health Care Reform this Spring: The Good, the Bad and the Obscure1

This article first appeared in the Daily Journal on May 18, 2012.

iStock_000018849339XSmall-250x1651The lack of growth in health care spending over recent years stands in stark contrast to the onslaught of health care regulations released by the federal government this spring. Due to the volume of such changes, pouring through this new iteration of codified health care reform can seem as Sisyphean as achieving actual compliance. The vigor and enthusiasm with which the federal government continues to add dimension to the 2010 Affordable Care Act leads many to believe that health care reform is here to stay, regardless of the U.S. Supreme Court decision due in June. With this in mind, all health care professionals would do well to familiarize themselves with the new structure imposed upon our system by the effects of reform. Rather than fret about its future, health care counselors are better served by understanding the bare bones at the foundation of this new structure.

The Good

Earlier this month the federal government released final regulations easing hospital conditions of participation (CoPs) in an attempt to decrease the burdens faced by providers and suppliers participating in federal health care programs (Medicare and Medicaid (Medi-Cal for California) in particular). These modifications, set forth in 42 CFR Parts 482 and 485, seek to simplify and even eliminate certain CoPs consistent with President Barack Obama’s January 2011 Executive Order directing federal agencies to employ the least burdensome approach that minimizes costs, simplifies duplicative regulations, and yet is still mindful of the American public and the need to preserve its freedom of choice.

Hospitals must be in compliance with federal CoPs in order to receive Medicare and Medicaid payments, a determination usually made by one of three national accreditation programs, which include the Joint Commission, Healthcare Facilities Accreditation Program (HFAP) and, most recently, Det Norske Veritas Healthcare (DNV Healthcare). Through observations, interviews and document and record reviews that take place during accreditation surveys, hospitals must satisfy all appropriate standards to ensure that Medicare and Medicaid beneficiaries receive treatment that is both safe and superior.

Recent regulations have further revised and clarified the requirements for hospital governance, confirming that multi-hospital systems can maintain a central governing body where appropriate, provided that it includes one or more members of the hospital medical staff. The federal government commented: “[T]here is an important and essential symbiotic relationship that should exist between a hospital’s governing body and its medical staff.” The new regulations also permit a hospital’s medical staff to expand its membership to include non-physician practitioners (such as physician assistants, pharmacists and advanced practice registered nurses), provided such inclusions are consistent with hospital bylaws and state law (including scope of practice laws), and further allow podiatrists to take new leadership roles at a hospital. It should be noted, however, that registered dieticians might not be included in this pool of non-physician practitioners. … Read more →

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Healthcare Reform: A Time To Wait, or Expiate?0

This article first appeared in Becker’s Hospital Review on April 12, 2012.

If Dante Alighieri had written an epic poem describing the recent evolution of American healthcare, it might have much in common with his famous Purgatorio.   As the nine U.S. Supreme Court Justices continue deliberation  on the fate of the 2010 Affordable Care Act, it is unclear whether our nation’s healthcare system is heading toward Inferno or Paradiso. While experts on both sides of the aisle attempt to divine the secret codes shared between Justices over a record-breaking three days of oral argument, the rest of us have little choice but to wait until summer for clarity.

In the 25 months since President Obama signed the Patient Protection and Affordable Care Act into law, the structure of our modern American healthcare system has changed dramatically, dividing the nation down political lines amid questions of constitutionality. With the bill currently under debate in our highest court, now is the time to consider the practical implications of an adverse ruling, and what the resultant ramifications may entail for the future of both the Affordable Care Act and the patients for whom the legislation was designed to protect. … Read more →

Administrative, Clinical, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News

HAPPY ANNIVERSARY TO THE AFFORDABLE CARE ACT0

March 23 marks the two-year anniversary of President Barack Obama’s ambitious and controversial Patient Protection and Affordable Care Act. While the ultimate legacy of this landmark legislation remains to be seen, its fate will soon rest in the hands of the nine U.S. Supreme Court Justices, and then possibly the Electoral College.

With talk of constitutional challenges and potential repeal sharing headlines almost every day, now is the perfect opportunity to trace the changes in American health care over these past 24 months.

As our health care system continues to experience growing pains, certain basic tenets of reform have already made their mark, and may be difficult to retract in the event of the bill’s failure. The number of insured young adults under the age of 26 has continued to rise since 2010, as has the estimated 105 million Americans who no longer face lifetime limits on health benefits. Statistics also point to 50,000 newly insured who had in the past failed to qualify for health insurance due to pre-existing conditions.

Across the nation, individual states are gearing up for health insurance exchanges, while hospitals and physicians prepare for monumental changes in the Medicare reimbursement infrastructure as it transitions from a historically cost-based to a performance-driven platform.

Under the reform bill, the Federal Government has increased its presence with an unprecedented focus on eliminating health care fraud, abuse and waste.

Thanks to the Office of the Inspector General, Centers for Medicare & Medicaid Services and Department of Justice having procured health care fraud-related settlements and judgments in excess of $3 billion last year (capping the largest three-year streak in history with a total of $8.7 billion since January 2009), health care providers are now busy crafting or fine tuning their own custom-tailored compliance programs.  At the same time, providers must also fight off Medicare and Medicaid related audits from a number of newly created entities known only by their acronyms (RACs, MICs, MACs and ZPICs to name a few).

No matter what effects the Supreme Court’s decision and upcoming elections may hold for the Affordable Care Act, it is clear that American health care will never be the same.

Only time will offer any definitive perspective for us to evaluate the changes it has imposed upon the delivery of our nation’s health care.

Welcome to health care reform, year three, as it promises to be a busy one.

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Adjudicating health care reform by dissent0

This article first appeared in the Daily Journal on March 15, 2012.

The procedural infrastructure within which the nation’s judicial system operates is as important as the canons of law the Courts espouse. In many ways, the doctrine of justiciability affords the federal courts an opportunity to rule with finality in matters of the U.S. Constitution, while at the same time ensuring that an appropriate distance is maintained between the three branches of federal government. Given the numerous preconditions upon which certiorari is determined, rightful passage through the Supreme Court’s Corinthian columns can seem as improbable as procuring a return ticket across the river Styx.

However, those for whom certiorari is ultimately granted can count on a few basics from the Supreme Court, including a session each first Monday in October, quill pens on counsel tables, and the Court’s own general prohibition from issuing judicial advisory opinions. In commenting upon this most revered prohibition, Chief Justice Earl Warren noted: “When the federal judicial power is invoked to pass upon the validity of actions by the Legislative and Executive Branches of the Government, the rule against advisory opinions implements the separation of powers prescribed by the Constitution and confines federal courts to the role assigned them by Article III.”[1] … Read more →

Administrative, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory

Health care reform experiences growing pains1

This article first appeared in the Daily Journal on January 27, 2012.

In its attempt to modify the basic structure of our nation’s health care system, President Barack Obama’s Affordable Care Act has understandably caused a series of rifts between competing factions within the health care industry.  As the entire nation waits to discover its ultimate fate, the fledgling program continues to promote conflict as it experiences growing pains, exemplified by recent modifications to federal regulations that push the invisible line separating church and state from a health care perspective. With an eye to the future, the Affordable Care Act must move cautiously in its attempt to revamp the foundations of health care, fending not only for its survival in the political arena, but in terms of constitutionality as well.

At its core, the Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act (known colloquially as the “Affordable Care Act” or “health care reform”), promotes preventative measures designed in theory to eliminate health issues before they start. With such a sweeping directive, it is certainly understandable that constitutional challenges abound within, yet two of the more recent and most highly publicized concerns stand at opposite ends of the spectrum.

Last week, Health and Human Services Secretary Kathleen Sebelius issued a brief news release detailing a controversial August 2011 interim final rule that was specifically created to require health insurance plans to cover preventative services for women, including contraceptives, without charging a co-pay, co-insurance, or deductible.  Under this interim final rule, however, certain non-profit religious employers retained the option to omit contraceptive services from their employee insurance plan. Announced last week, the final decision now guarantees that women with health insurance as of Aug. 1, will be allowed access to all federally recommended preventative services, including contraception measures approved by the U.S. Food and Drug Administration. … Read more →

Administrative, Community, Health Care Law, Health Care Reform, Historical, Hospitals, News, Regulatory

Lessons From My Father0

This article first appeared on the PBS affiliated website This Emotional Life.

“Everything in moderation, including moderation.”  –Oscar Wilde, Irish writer and poet

When it comes to understanding what it means to be a man, little boys typically look toward one specific individual, Dear Old Dad.  What is not so consistent, however, is the manner in which a father chooses to undertake his role. Nowhere else is the drive to impart all that he has learned so strong and the possibility of instilling hard-won wisdom so pronounced as when a father looks at his eager young son. And yet, for this very reason the school of fatherhood boasts a subjective curriculum at best, as the competency of the teacher pales in comparison to the ways in which the student will go on to apply these lifelong lessons, many of which have been handed down through generations, whether knowingly or not.

Several thousand years of fiction tell us all we need to know about how tenuous the influence of a mature man upon his children can be.  From King Laios of Thebes (the biological father of Oedipus) to Wilbur Meecham (the tyrannical father of Ben) to Carlisle Cullen (the eternal father who adopted Edward), the most valuable lessons often emanate from the reactions of the son rather than the actions of the father. In truth, a man’s best intentions may fall upon deaf ears or be misinterpreted by a youth struggling to carve the foundations of his own identity, and sometimes the best we can hope for is that a little luck and our unspoken influence through way of example will provide the necessary navigational instincts for our children as they pass through whatever storms may confront them.

The relationship between father and son is always complicated and in each case unique, with every example of success or failure providing a new interpretation on what it means to be a father. If that was not enough, there is never a guarantee that an idyllic father will raise a comparable son, or that the child of an atrocious man will ultimately follow in his ancestor’s malevolent footsteps. This cumulative nature of fatherhood is in many ways for the best, as nearly every boy at one point or another finds himself determined to be anything but his father. Today, however, as I read that rhyming masterpiece of Dr. Seuss, Hop on Pop, to my 10-month old son on what would be my own father’s 75th birthday, I realize that not only am I deep into uncharted territory, but there is no way of knowing what aspects of history might repeat themselves. Without any guidance or source of direction, how will I ever know if I am a good father?

In looking for answers, I find it hard to gather much from my siblings on what it means to be a father, as both my brother and sister learned from the same role model I did. While fiction and history provide a number of cautionary tales, they are blueprints at best, to be relied upon loosely.  But even as I try to learn from the experiences of friends whose opinions I respect on this subject, there remains the ever-present fact that every case is different, from the point of view of both father and son.  Though one friend is in my opinion an exemplary role model for his children, I cannot help but wonder how much of his inspiration stems from his contentious relationship with his own father, the secrets of which are lost on me and my very different experiences growing up. An example in stark contrast does little more than cast an even brighter light on the many different facets that can shape the paternal instinct. … Read more →

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