OIG challenges industry to come up with an upgraded statistical sampling tool

CMS handles more than a trillion dollars in Medicare and Medicaid claims every year. Because not every claim can be scrutinized, statistical sampling is essential for effective oversight of these claims. The current sampling tool, RAT-STATS, was originally designed by the HHS Office of Inspector General (OIG) to give nonexperts a robust method for selecting statistically valid samples. It is the primary statistical tool for OIG’s Office of Audit Services. Although OIG does not require the use of RAT-STATS, many providers download the software and use it in their efforts to fulfill the claims review requirements for corporate integrity agreements or provider self-disclosure protocol.

The OIG has recently announced the launch of the Simple Extensible Sampling Tool Challenge (Challenge) to develop the foundation for an upgraded version of RAT-STATS. According to the OIG, while the current version of RAT-STATS is well validated, its user interface can be difficult to navigate and the underlying code makes the software costly to update. Therefore, the OIG needs a new, modern version of the software that is easy to use and can be extended in a cost-effective manner.

Current RAT-STATS

The RAT-STATS software was originally created in 1978 and has gone through several upgrades since then. Unlike a full statistical package that attempts to answer all types of questions for a wide range of users, RAT-STATS serves as a streamlined solution to handle the specific task of developing valid statistical samples and estimates within the health care oversight setting.

For example, an OIG investigator may pull a simple random sample in order to estimate damages for a provider suspected of fraud. RAT-STATS then generates valid pseudo-random numbers and outputs all of the information needed to replicate the sample. Once the investigator finishes reviewing the sample, he or she can then enter the results into RAT-STATS to get the final statistical estimate. While the investigator may need some basic training in statistics, they do not need the same level of expertise as would be required to navigate the many options available in a full-service statistical or data analysis package.

The Challenge

In order to complete the Challenge participants must create a software package that replicates the operation of four of the functions of the original RAT-STATS software: (1) single stage random numbers;
(2) unrestricted attribute appraisal; (3) unrestricted variable appraisal; and (4) stratified variable appraisal.

Teams of one or more members can participate in this Challenge. Each team must have a captain. Individual team members and team captains must register in accordance with the registration process set forth in the Federal Register notice.  The team captain is to serve as the corresponding participant
with OIG about the Challenge and to submit the team’s Challenge entry. While the OIG will notify all registered Challenge participants by email of any amendments to the Challenge, the team captain is expected to keep the team members informed about matters germane to the Challenge.

Submissions must meet all of the 20 rules and requirements outlined in the Federal Register notice. The technical specifications behind the four RAT-STATS functions along with 10 test datasets are available on the OIG website.

The Challenge began on September 28, 2016. The submission period runs from September 28, 2016, to May 15, 2017. The judging period runs from September 28, 2016, to June 15, 2017. A winner will be announced no later than July 1, 2017. The grand prize is $25,000.

 

Arizona KidsCare restart estimated to help 40K children

Arizona will begin taking applications on July 26, 2016, for its government-sponsored health-insurance program KidsCare; coverage will begin September 1, 2016. As a result, the population of uninsured Arizona children, currently around 162,000, is projected to drop significantly this fall, as an estimated 34,278 Arizona children would be eligible for KidsCare upon reinstatement of the program.

KidsCare, the Arizona version of the Children’s Health Insurance Program (CHIP), is administered by the state’s Medicaid program, which is known as the Arizona Health Care Cost Containment System (AHCCCS). Officials with AHCCCS expect that within its first year of being newly active, KidsCare will enroll 30,000 to 40,000 Arizona children. Arizona is the only state without an active CHIP program. According to a study by the Center for Children and Families at Georgetown University, the state has the third-highest rate of uninsured children in the U.S.

Opponents of KidsCare have expressed concern that Arizona will eventually have to pick up the tab for the program, as federal dollars are only appropriated to cover the cost of the program for the next year. Supporters said reopening the program was the moral thing to do for Arizona children.

KidsCare

Enrollment in KidsCare was frozen in 2010 after Arizona decided to cut eligibility and phase out CHIP benefits over time. KidsCare II, a temporary hospital financing agreement meant to fill the gap due to frozen enrollments beginning in 2010 until new coverage options were available to Arizona families with the implementation of the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148), was terminated at the end of January 2014.

An earlier Georgetown study observed that the termination of KidsCare resulted in families paying more for alternative subsidized health care coverage while receiving fewer benefits under that coverage (see Arizona CHIP discontinuation results in higher prices, less coverage, Health Law Daily, May 9, 2014).

Kusserow on Compliance: OIG identifies the top HHS challenges

The HHS Office of Inspector General (OIG), in its mid-year review of its work plan, included a summary of the Top Management Challenges (TMCs) facing HHS, along with associated recommendations for improvement. Some of the recommendations reflect persistent and concerning vulnerabilities that the OIG has highlighted for HHS over many years, while others forecast new and emerging issues for the upcoming year and beyond. The current TMCs are identified as follows:

  1. Protecting an expanding Medicaid program from fraud, waste, and abuse. Enrollment in Medicaid and Children’s Health Insurance Program (CHIP) programs has grown by 15 million people since October 2013, and the program remains a top management priority given long-standing program integrity issues and expanding eligibility. CMS needs to provide more oversight of Medicaid expansion, oversight of Medicaid managed care, improving the effectiveness of Medicaid data and systems, state policies that inflate federal costs, and ensuring quality care for Medicaid beneficiaries.
  1. Fighting fraud, waste, and abuse in Medicare Parts A and B. HHS must find ways to reduce wasteful spending and promote better health outcomes at lower costs in reducing improper payments, preventing and deterring fraud, and fostering economical payment policies. More effort is needed to better ensure that Medicare payments are accurate and appropriate, through (a) better identification of problems; (b) more timely recovery of overpayments; and (c) implementing better safeguards to prevent recurrence of problems. In that CMS relies on contractors for most of these crucial functions, the agency must ensure more effective on their part. The Medicare appeals system remains broken and needs fundamental changes to resolve appeals efficiently, effectively, and fairly.
  1. Meaningful and secure exchange and use of electronic information and health information. Technology, including electronic health records (EHRs), offers opportunities for improved patient care, more efficient practice management, and improved overall public health. HHS needs to find ways to measure the extent to which EHRs and other health information technologies (ITs) improve, and ensure that adopted policies advance towards this. HHS faces challenges safeguarding privacy and security of health IT, improving information flow, and ensuring a return on health IT investments. Threats to information privacy and security are evolving. Although progress was noted, more remains to be done to address health IT privacy and security issues, as well as the flow of information.
  1. Administration of grants, contracts, and financial and administrative management systems. HHS is the largest grant-making organization in the federal government, with over $402 billion awarded in FY 2014. The scale of this program can be understood by comparing it with the entire Department of Defense budget of $529 billion for the same period. Increased oversight is need for better grants and contract management, financial statement audit revelations of defective system controls, and improper payments. More can be done to identify poorly performing grantees and those at risk of misspending federal dollars.
  1. Ensuring appropriate use of prescription drugs. The prescription drug coverage is provided for 41 million Medicare Part D and another 71 million Medicaid beneficiaries. Part D is the fastest-growing component of the Medicare program. Management of these drug programs faces numerous challenges in oversight, drug abuse and diversion, and questionable, inappropriate utilization, and enrolling prescribers. Among actions needed include requiring sponsors to report probable fraud, waste, and abuse identified and corresponding actions.
  1. Ensuring quality in nursing home, hospice, and home- and community-based care. Fraud, waste, and abuse with nursing home, hospice, and home- and community-based care continues to be a serious problem. More needs to be done in improving internal controls and better guidance and training for surveyors to ensure that nursing homes with recorded quality and safety issues correct their deficiencies.
  1. Implementing, operating, and overseeing the health insurance marketplaces. The marketplaces are critical elements of the Patient Protection and Affordable Care Act (ACA). Initially the challenges centered on implementation, operation, and oversight of the marketplaces. Looking forward, the OIG anticipates challenges with payments, eligibility determinations, management and administration, and the security of the marketplaces; and calls upon CMS to strengthen marketplace operations and work with states to ensure compliance with federal requirements.
  1. Reforming delivery and payment in health care programs. In January 2015, the HHS Secretary announced goals to foster better care, smarter spending, and healthier people by tying traditional Medicare payments to alternative payment models (APMs), and to quality and value. CMS must establish policy, infrastructure, data systems, program integrity, and oversight mechanisms to successfully implement these and other changes. CMS must also strengthen Medicare Advantage to ensure that benefits are provided only to eligible beneficiaries and that data are available for fraud prevention and detection.
  1. Effectively operating public health and human services programs. HHS must focus on public health preparedness and emergency response, enabling access to and quality of services, and protecting vulnerable populations. Continued collaboration of federal, state, and communities is necessary for proper disaster response.
  1. Ensuring the safety of food, drugs, and medical devices. The FDA must address areas of particular high risk, including: compounded drugs, imported food and drugs, food facilities, off-label promotion and kickbacks, and dietary supplements.

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 © 2016 Strategic Management Services, LLC. Published with permission.

Hearing addresses physicians’ MACRA preparations

Lawmakers and physician leaders discussed the steps physicians are taking to prepare for Medicare changes under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (P.L. 114-10) at an April 19, 2016, hearing held by the House Committee on Energy and Commerce, Subcommittee on Health. The hearing addressed the promise of the new law, the necessary preparations physicians must take to benefit from the legislation, and points of caution that should be areas of focus for CMS as the agency works on regulations the agency is expected to release this spring.

Benefits

The physician leaders who testified at the hearing celebrated the patient oriented nature of the legislation. They also applauded the way MACRA seeks to move Medicare forward through the elimination of the sustainable growth rate (SGR), the streamlining of programs through the Merit-Based Incentive Payment System (MIPS), and the reliance on alternative payment models (APMs). Barbara McAneny, testifying on behalf of the American Medical Association (AMA), noted that in addition to resetting and improving quality reporting, “MIPS has the ability to streamline measures, reduce reporting burden, create flexibility to report on clinically relevant measures, encourage participation, and overall improve care.”

Incremental

Despite the benefits of the transitions under MACRA, Jeffrey Bailet, President of the Aurora Health Care Medical Group, testified as to the need for regulators “to proceed cautiously” during the transition. Bailet warned that as CMS takes on the dramatic transition from fee-for-service towards MIPS and APMs, the agency needs to be aware there is a learning curve for many providers, which comes alongside new financial risk. As a result, Bailet recommended that the MIPs and APM regulations “providing an incremental approach that includes flexibility and rational exposure to financial risk.”

Burnout

Robert McLean, testifying on behalf of the American College of Physicians, raised concerns regarding physician burnout and relayed anecdotes of physician complaints regarding other laws and regulations like those related to electronic health records, prior-authorizations, and payment penalties. While McLean acknowledged the importance of the goals of the “triple-aim”—(1) improvement of the patient experience; (2) improving health populations; and (3) reducing per capita costs—he testified that the triple-aim should become the quadruple-aim with a fourth goal related to physician burnout. Specifically, he recommended that stakeholders focus on a fourth goal of “improving the work life of health care clinicians and their staff.” To achieve the goal, McLean recommended less burdensome reporting and the development of pathways for patient-centered medical homes.

Education

To prepare primary care physicians, Robert Wergin, Board Chair of the American Academy of Family Physicians (AAFP), testified that the AAFP has developed a comprehensive, multi-year member education, and communications effort called “MACRA Ready.” The effort includes regularly updated educational resources, tools, resources, videos, and assessments. Although Wergin acknowledged that without a Proposed rule it is difficult to identify what exactly CMS will do under MACRA, he noted that the AAFP would like CMS to address flaws that undervalue primary care, ensure the existence of APMs for primary care physicians, avoid over complex regulation, and grant greater flexibility in the initial MACRA performance year because January 1, 2017, is an unrealistic date to begin measuring performance because the regulations are not yet finalized.