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.

 

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.

Substance abuse data suppression: safeguarding privacy or hindering research?

In the United States, the use of drugs like cocaine is down, but a more socially accepted but no less dangerous type of substance abuse is persistent and widespread. It has been reported that opioids are the leading cause of drug deaths in the United States. Prescription drug abuse has become such a problem throughout the country that the Centers for Disease Control and Prevention (CDC) has stated that prescription drug overdose is an epidemic. The White House website even has a section devoted to combating prescription drug abuse. Despite the fact that the United States seems awash with substance abuse problems, the New York Times is reporting that researchers who would like to study the association between drug users and the illnesses that disproportionately affect them are thwarted because of a CMS policy that has been limiting their access to records vital to research.

In December of 2014, researchers were shocked to discover that during the prior year, HHS CMS had begun to redact Medicare records that contained any claim codes related to substances abuse diagnoses. In 2014, CMS began to do the same to Medicaid records. CMS justifies the redaction of any Medicare or Medicaid files containing substance abuse codes by citing to the confidentiality of drug and alcohol abuse patient records regulations (42 C.F.R. Sec. 2). According to CMS, “when researchers need access to more detailed claims information than that which is included in limited data set files or public use files, there is a risk that the data could be used to identify a patient receiving treatment for alcohol or drug abuse. Therefore, to ensure compliance with [Substance Abuse and Mental Health Services Administration (SAMHSA)] regulations, after gathering requested data for a researcher, CMS redacts any substance abuse related claims from the resulting research identifiable files based on codes within the claims. CMS implemented this in November 2013 for Medicare claims and March 2014 for Medicaid claims.” The records redactions impacted 7 to 8 percent of all inpatient hospital records and an estimated 4.5 percent of inpatient Medicare claims and about 8 percent of inpatient Medicaid claims.

According to a recent article in the New England Journal of Medicine, the suppression of the data has not only had a chilling effect on researcher’s work, but could also negatively impacted health care reform and the work of accountable care organizations (ACOs)and health information exchanges because the consent requirements make patient data sharing related to substance abuse problems nearly impossible. As a result, substance abuse information is removed from the records, which undermines the ability of the health care providers to improve both case and efficiency. Also, the suppression of the data may extend from its intended target because many of the withheld data relate to not to substance disorder admissions, but conditions that are made worse by substance abuse. Additionally, some have argued that the suppression of data also limits health care providers’ ability to care for patients because doctor’s offices and hospitals cannot share data on substance abuse. Therefore, a doctor may be unknowingly prescribing pain killers to an individual with a diagnosed painkiller addiction, but would have no way of knowing it due to the limitation on data. This may true even if the doctor is working with another to coordinate the patient’s care.

There may be a glimmer of hope for researchers as Politico is reporting that the suppression of data may soon be coming to an end as health officials are planning a Proposed rule that would grant researchers access to substance abuse data. Pam Hyde, Administrator for SAMHSA, reportedly stated that it is trying to grant researchers access to the data without having to wait for Congress to act to change the law: “We are having to work with the law and the regs and the lawyers about what it takes to get that and still be in line with the way the law is currently written,” she said. However, some have cautioned that excitement may be premature, as the proposed rule could be stalled at any point during the lengthy rule-making process.