Highlight on New York: Governor, task force plan to end AIDS by 2020

On June 29, 2014, Governor Andrew Cuomo announced an initiative with an ambitious goal: to end the AIDS epidemic in the state by the end of 2020. He appointed a task force of 63 members and charged it to develop a plan to make it happen.

The targets:

  • reducing the number of new AIDS cases per year to 750, about the same as the number of new cases of tuberculosis;
  • reducing deaths from AIDS to zero; and
  • ending discrimination against people with HIV.

The three points of Cuomo’s initiative, called “Bending the Curve,” were:

  • identifying people with undiagnosed HIV and connecting them to health care;
  • connecting those diagnosed as HIV-positive with treatment, including antiviral therapies to suppress the virus and stop the transmission of the disease; and
  • providing access to pre-exposure prophylaxis (PrEP) to individuals at high risk for AIDS to keep them HIV-negative.

 Previous progress

At the peak of the epidemic, in 1993, there were 14,000 new diagnoses in New York each year. In 2014, there were about 3,000. The number of New Yorkers living with AIDS has grown—from 112,000 in 2002 to 132,000 in 2012—because the number of AIDS-related deaths has declined. Because medication has been made available, between 44 percent and 51 percent of infected New Yorkers have suppressed the virus, meaning that it is no longer at a detectable level.

Nationally, the number of new infections per year has remained stable at about 50,000, and only about 25 to 30 percent of people with HIV have reached suppression.

Related actions taken

Routine screening for HIV and targeted screening of individuals at risk are key to detection and treatment, but it has been necessary for the state to remove legal obstacles in recent years. In 2014, the law requiring written consent to HIV testing was amended to require only verbal consent, as is standard for other laboratory tests. Some prosecutors and police departments have forsworn or limited the practice of confiscating condoms for use as evidence in criminal cases involving prostitution.

The task force believes that transgender individuals are at higher risk for AIDS, so that legal protections against discrimination and coverage of their unique health care needs are helpful in the achievement of the goal of minimizing the spread of the disease. Therefore, the state Department of Health has adopted regulations requiring Medicaid to cover the treatment of gender dysphoria, including medically necessary gender reassignment surgery. The legislature also is considering bills that would ban discrimination based on gender identification. Both Medicaid and most private insurers will cover daily medication that prevents the transmission of the virus to the partners of HIV-positive individuals.

The task force and the blueprint

The task force formed four committees, each with its own focus: care, prevention, housing and supportive services, and data. They held public listening sessions and considered some 300 recommendations submitted to them. They then formulated 44 recommendations and tied each to at least one of the three elements of the Bending the Curve initiative.

The blueprint was presented to the governor in late April, 2015. The recommendations go beyond the goal of reducing new infections to 750, with the aim of reaching zero by 2025. An essential part of the plan is continuous monitoring to identify the populations currently most affected or at greatest risk of contracting HIV, and, as well, those most affected by “systemic health, economic, and racial disparities that act as catalysts for new infections.”

 

Kusserow on Compliance: OIG reports on background checking by home health agencies

In response to a congressional request, the HHS Office of Inspector General (OIG) conducted a review to analyze the extent to which Home Health Agencies (HHAs) employed individuals with criminal convictions and to explore whether these convictions should have—according to State requirements—disqualified them from HHA employment. HHAs provide care—usually unsupervised—to patients in their homes and ensuring that their employees undergo a minimum level of screening would help protect the safety of Medicare beneficiaries. Home health programs have been a high priority for Medicare; Medicaid is intended to provide an alternative to institutional care for people with severe disabilities and it is intended that the needed services be delivered in a beneficiary’s home. This industry sector accounts for more than $20 billion paid by Medicare on behalf of 3.4 million beneficiaries with another estimated $15 billion in outlays paid by Medicaid programs.

This is a sensitive issue area as no one wants someone with a violent criminal history or one of committing thefts to be sent to care for beneficiaries in their home. To underscore, government concern with HHAs, including those concerns expressed by the Department of Justice (DOJ) and OIG, have found considerable evidence to recognize that home health is among the most vulnerable healthcare programs to fraud and abuse. The Government Accountability Office (GAO) recently reported 40 percent of all fraud convictions initiated by a group of Medicaid fraud-control units were for home health. CMS has been active in curbing problems in this arena by making uses of authority under the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) to use temporary enrollment moratoria on home health providers in geographic areas of disproportionate crimes.

In their new report, the OIG noted that there are no federal laws or regulations that require HHAs to conduct background checks prior to hiring individuals or to periodically conduct background checks after individuals have been hired. State requirements for background checks vary as to what sources of information must be checked, which job positions require background checks, and what types of convictions prohibit employment. Though not stated in the report, what should be noted is that the background sanction-screening against the OIG’s List of Excluded Individuals/Entities (LEIE) is necessary and mandated in most states, along with screening State Medicaid sanction databases. However the problem is that most local criminal convictions are not related to violations of Medicare and Medicaid laws or regulation; and therefore not included in state reporting to the OIG LEIE.

In conducting the review, the OIG obtained a sample of Medicare-certified HHAs regarding all individuals they employed. It compared employee data with criminal history records to identify individuals with criminal convictions who were employed by the sampled HHAs. It also selected six employees for an in-depth review who had convictions for crimes against persons in the last five years and/or were registered sex offenders. Finally, it evaluated whether compliance with state laws would have led to disqualification of these six employees.

Findings

  • All HHAs conducted background checks of varying types on prospective employees.
  • Approximately half also conducted periodic checks after the date of hire.
  • Four percent of HHA employees had at least one criminal conviction that may or may not have disqualified them from employment.
  • Criminal history records reviewed were not detailed enough to enable a definitive determination of whether employees with criminal convictions should have been disqualified from HHA employment.
  • In-depth review of the six employees found that three had convictions for crimes against persons that would disqualify them from employment in HHAs, with the remaining three with convictions did not disqualify them from employment in their respective states.

Recommendation

CMS should promote minimum standards in background check procedures for HHA employee background checks by encouraging more states to participate in the National Background Check Program. CMS concurred with this recommendation.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2015 Strategic Management Services, LLC. Published with permission.

 

Low-volume hospitals bring high risks: a drive might save your life

Patients who undergo procedures at low-volume hospitals are subjecting themselves to an increased risk of complications and death because surgical teams at those hospitals perform too few procedures to maintain adequate levels of skill. According to a U.S. News & World Report analysis, large numbers of low-volume hospitals continue to put patients at increased risks despite three decades of research tying low-volume hospitals to higher incidents of complications and death.

Increased risk

According to an evaluation of five procedures from the U.S. News analysis, as many as 11,000 deaths might have been prevented between 2010 and 2012 if patients had undergone procedures at the highest-volume fifth of hospitals rather than the lowest-volume fifth. Some evaluations suggest that if other procedures are considered, tens of thousands of deaths might have been avoided. The increased risk of dying at a low-volume hospital from relatively safe procedures is staggering. For example, at one 25-bed Colorado hospital, the relative risk of death for elective knee replacement patients at the hospital was 24 times the national average. Similarly, at a 331-bed medical center in Florida, the relative risk of dying following a hip replacement was nine times the national average and, at a 316-bed New Jersey Medical Center, the risk for patients who had heart bypass surgery was four times above the national average.

Ultra-low-volume

Ultra-low-volume hospitals were identified as those which treated “fewer than 25 traditional Medicare inpatients from 2010 through 2012 for nearly 20 frequent procedures and conditions.” Between 2010 and 2012, ultra-low-volume hospitals performed or treated an average of 3.3 hip replacements per year, 3.7 knee replacements per year, 4.1 basic heart bypass surgeries per year, 3.9 cases of heart failure per year, and 4.3 cases of chronic obstructive pulmonary disease per year. Knee-replacement patients at the ultra-low-volume hospitals had “double the national average death risk and a 25 percent higher rate of readmission because of post-discharge complications.” Similarly, “hip-replacement patients faced a 77 percent higher risk of death and a 25 percent higher risk of readmission.” The problem stems from the simple fact that surgical teams at low-volume hospitals are out of practice.

Patients

The problem is exacerbated by the fact that few patients ask hospitals or physicians how many similar procedures a hospital has treated. U.S. News offers questions that patients can ask hospitals when trying to determine whether a low-volume hospital is a safe place to undergo a particular procedure. The findings of the analysis suggests that longstanding patient preference for local care should give way to a preference for travel and better outcomes, if safety is what patients are after.

Despite expanded health coverage, expensive ER visits are on the rise

Despite the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), 75 percent of emergency physicians indicate that emergency room (ER) visits are on the rise. When the American College of Emergency Physicians (ACEP) conducted this poll one year before, less than half of physicians reported increases. ACEP’s president, Dr. Michael Gerardi, stated that emergency care remains a valuable model of care, pointing out that the ER is the only place that remains open at all hours and that no one is ever refused care.

Polling results

Poll respondents reported that the availability of alternative models of care, such as urgent care centers and triage lines conducted by telephone, has not reduced the volume of ER visits. The large majority said that the severity of illnesses among these patients is either the same or has increased, compared to the past. Over half of respondents also said that the number of Medicaid patients is rising, as well.

ACA

The ACA’s goal of seeing more people covered by health insurance was furthered by the individual mandate, requiring people to have health care coverage or pay a penalty. ACEP reports that the rise in ER visits comes after the date that the individual mandate went into effect. The ACA also provided an opportunity for states to expand Medicaid programs to cover those who were previously ineligible, with additional financial contributions from the federal government. ACEP notes that a Health Policy Alternatives report also indicates that efforts to direct Medicaid enrollees away from ERs to primary care is failing.

More patients, no providers

Despite Medicaid expansion covering more patients, providers cannot be forced to see these patients. Medicaid reimburses providers at the lowest rate, although the ACA includes a provision to offer a slightly higher rate to primary care physicians willing to treat Medicaid enrollees. However, since the ACA resulted in more coverage by private insurance that typically pays providers at much higher rates, providers are even more interested in boosting their bottom line with those patients. Even providers listed on Medicaid managed care plans are busy, with median wait times for appointments at two weeks and a quarter of providers forcing patients to wait over a month.

This problem is exacerbated by the shortage of providers overall, particularly primary care providers. A 2014 report from the Association of American Medical Colleges (AAMC) indicated that the primary care physician shortage would reach 45,000 by 2020. This shortage is explained by aging physicians, Medicaid expansion, and more people newly insured through the ACA. In 2015, these projections were updated through 2025, indicating that the shortfall of primary care physicians would be somewhere between 12,600 and 31,100. The lower numbers will require aggressive changes to payment and delivery models, such as accountable care organizations (ACOs). ACOs unite providers and coordinate patient care in an effort to save government funding. However, provider participation is voluntary.

Emergency model of care

According to Dr. Orlee Panitch, an ACEP fellow, access to both primary and specialty care for Medicaid patients is not timely, resulting in ER visits as the last, or only, resort. Panitch is also concerned by some state policies that discourage Medicaid patients from seeking emergency care, noting that it could have dangerous results. Gerardi points out that this polling offers evidence that the emergency care model is valuable and desirable. There is evidence that this model is evolving. The Mayo Clinic offers a joint Emergency and Urgent Care Center, where triage evaluates the seriousness of a patient’s condition and determines the appropriate level of care. Directing patients to urgent, rather than emergency care, in situations that are not life-threatening or do not warrant immediate attention may result in cost savings. Although information is available from places such as Blue Cross Blue Shield to help patients determine where to seek care, a possible emergency or even urgent situation might not allow a patient to take precious time to make these decisions.