Few U.S. hospitals attain five-star quality of care

Only 2.2 percent of U.S. hospitals earned a five-star quality rating from CMS in its Overall Hospital Quality Star Rating (Star Rating) system, which reflects the level of patient care received. According to a CMS data brief preview and evaluation, 934 hospitals, or 20.3 percent, received a four-star overall hospital quality star rating. The most common rating was three stars, which was received by 1,770 hospitals, or 38.5 percent. Two stars were given to another 723 hospitals, or 15.7 percent, and 133, or 2.9 percent, received only one star.

Notably, another 937 hospitals, or more than 20 percent, were not assigned a rating. No star rating is assigned to hospitals that do not report or do not have the requisite minimum amount of data, which can occur for small or new facilities.

CMS’ Star Rating takes 62 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars. Quality measures range from the routine care an individual receives when being treated for heart attacks and pneumonia to quality measures that focus on hospital-acquired infections, such as catheter-associated urinary tract infections.

Transparency

CMS believes that star ratings spotlight excellence in health care quality and make it easier for consumers to use the information on the Hospital Compare website (see Care to compare? Hospital five-star rating system now available, Health Law Daily, April 16, 2015). This is consistent with the call for transparent, easily understood, and widely available public reporting found in the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). The ratings also support using quality measures as a key driver of health care system improvement.

CMS had previously delayed its intended April 21, 2016, release of overall hospital quality star ratings on its Hospital Compare website until at least July 2016. The delay was partly attributable to efforts raising concerns about whether the involved methodology for star ratings provided a fair, accurate, and meaningful representation of hospital performance.

Lawmakers and associations, alike, noted that a number of the quality measures that are the ratings’ foundation impact teaching hospitals that treat patients of low socioeconomic status, treat more complex patients, and perform various complicated surgeries (see Lawmakers’, hospitals’ wish upon star ratings temporarily granted, Health Law Daily, April 21, 2016).

$149M in grants awarded for primary care training, including nursing

The world of primary care is getting a major boost thanks to the Health Resources and Services Administration’s (HRSA) decision to issue over $149 million in grants. These will go to 12 workforce programs that will work to develop health professions training and prepare primary care providers to work in diverse, high-need areas. The grants will provide scholarships, support advanced nursing programs, train psychologists, and fund research.

Workforce efforts

HRSA hopes to encourage partnerships between various entities, including academic institutions, clinicians, and public health organizations, to address the additional needs of underserved communities. The workforce efforts include development of diverse, well-educated primary care providers, developing psychologists to use an integrated approach for behavioral health needs in underserved areas, clinical teaching and research improvements, and furthering primary care research.

Nursing grants

Several of the grants will allow nurses to focus on evolving their specialties. The advance education nurse traineeship will provide $22.9 million in grants to 69 programs, allowing advance practice nurses to develop their roles in primary care services for underserved communities, and the advanced nursing education grant will fund additional academic-practice partnership models for preparing advance practice nursing students to become providers. Other nursing grants include a bachelor of science in nursing (BSN) practicum, behavioral health integration, partial loan forgiveness for nursing faculty, diversity efforts, and a nurse anesthetist traineeship.

Premium-supported Medicare proposal spawns many questions, no solid answers

Medicare currently makes payments based on specific services, but policy discussion is swirling about changing the program to a premium support system that operates on capitation payments, or payments per person. The Kaiser Family Foundation (KFF) offered some answers to common questions that are now swirling after Rep. Paul Ryan (R-Wis) released a Republican health reform proposal that includes partially privatizing Medicare (see Ryan proposes ‘A Better Way’ to repeal Obamacare, Health Reform WK-EDGE, June 29, 2016). The KFF warned that out-of-pocket costs for beneficiaries could either rise or fall under the proposed plan, depending on various factors.

How would it work?

The new system would involve a federal payment made for each beneficiary toward a health plan purchase, either a private plan (like under Medicare Advantage), or traditional Medicare. Beneficiaries would be able to choose their plans. The KFF emphasized that that various premium support proposals provided over the last few years have key differences in how policies would work, including benefit specificity, health insurer rules, and payment setting.

The price tag

A premium payment system’s particular design will determine the amount of premiums and out-of-pocket payments. Premiums for covered services would vary by geography and plan. The Congressional Budget Office (CBO) found that total cost to beneficiaries would decrease if the federal payments were tied to the average plan bid but would increase if tied to the second lowest plan bid. A general decrease, however, does not mean that every beneficiary’s payments will go down. Most beneficiaries who remain in traditional Medicare would pay more.

One of the primary aims of such a system is to reduce federal spending. If plan competition increases and results in decreased premiums, and beneficiaries are incentivized to choose the most cost-effective health plan, long-term federal spending on the program could decrease. Like beneficiary costs, federal government costs depend on plan structure.

Effects on beneficiaries and providers

The preservation of particular benefits is currently unknown, as some proposals differ. Currently, Medicare Advantage plans must offer at least the amount of benefits a beneficiary would receive under traditional Medicare, but premium support proposals have not clearly established this requirement. Some proposals offer subsidies for low-income beneficiaries, but these may be insufficient to allow such individuals to select the plan they want. They may also need to switch plans frequently to avoid premium hikes. KFF believes that a premium support plan may erode traditional Medicare enrollment so much that providers may have fewer incentives to enroll in accountable care organizations and other payment reform efforts, and subsidized providers like teaching hospitals may not receive the financial support to which they are accustomed.

Highlight on Massachusetts: Will the CVS painkiller settlement be the first of many?

CVS Pharmacy, Inc. must essentially admit that it contributed to the opioid epidemic by filling forged prescription painkillers during what some consider to be the height of the epidemic. CVS has agreed to pay $3.5 million to resolve allegations that 50 of its stores violated the Controlled Substances Act by filling forged prescriptions for prescription painkillers more than 500 times between 2011 and 2014, which is currently one of the largest settlements of its kind.  The pharmacy has also entered into a three-year compliance agreement with the Drug Enforcement Administration (DEA) requiring it to maintain and enhance the programs it has developed in recent years for detecting and preventing diversion of controlled substances.

The allegations came after the federal government conducted two DEA investigations into CVS’ activities after receiving calls reporting forged oxycodone prescriptions. The first investigation involved CVS pharmacies throughout Massachusetts and New Hampshire and identified 403 instances at 40 CVS stores where forged prescriptions were filled. The second investigation, which focused solely on the Boston area, found over 120 filled forged prescriptions at 10 CVS locations. A handful of people were involved in nearly all of the forgeries involving an estimated street value of over $1 million.

Although the company had some protections in place, the government spent time looking into whether CVS pharmacists continually ignored red flags such as computer system band on individuals receiving addictive painkillers. “When pharmacies ignore red flags that a prescription is fraudulent, they miss a critical opportunity to prevent prescription drugs from entering the stream of illegal opiates on the black market…Although CVS is currently undertaking corrective steps to curb the tide of diversion, this settlement pushes CVS to go further and holds the company accountable for its past conduct,” said United States Attorney Carmen M. Ortiz commented on the settlement.

DEA regulations indicate that pharmacists have a responsibility to ensure that he or she is filling only valid prescriptions that were written for a legitimate medical purpose by a practitioner who is managing the care of that individual. The responsibility requires that pharmacists identify and resolve any red flags which may indicate that a prescription could be forged or is otherwise invalid.

“DEA registrants like CVS have a corresponding responsibility to dispense controlled substances in accordance with the Controlled Substance Act.  When pharmacies fail to adhere to these responsibilities, it allows for the diversion of prescription pain medication, which contributes to the widespread abuse of opiates, is the gateway to heroin addiction, and is devastating our communities,” said DEA Special Agent in Charge Michael J. Ferguson.

What this investigation makes clear is that authorities aren’t just looking at the forgers themselves. Pharmacies will need to ensure that they are complying with the DEA regulations and that they are keeping a lookout for any red flags. As is the case with CVS, pharmacists who look the other way will be forced to face stiff penalties for their failures to keep their eyes open.