The CONNECT for Health Act suggests the future isn’t too remote

A new piece of legislation would increase the use of telehealth and remote patient monitoring (RPM) in the Medicare program. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act, a bipartisan piece of legislation, is aimed at cutting health care costs while improving care outcomes. The bill is premised on the belief that telehealth is the future of medicine and that the quality of care can be greatly improved, in a cost effective way, through better contact between patients and providers.

Provisions

The CONNECT for Health Act would loosen current restrictions on Medicare reimbursement for telehealth and RPM services. Specifically, the legislation would allow certain providers to use telehealth and RPM without many of the current 42 U.S.C. §1834(m) limitations, which include originating site restrictions, geographic limitations, restrictions on store and forward technologies, limitations on distant site providers, and limitations on covered codes. The act would also permit providers to use telehealth and RPM in alternative payment models without most of the Section 1834(m) restrictions. The act would allow RPM of certain patients with chronic conditions, permit more facilities to serve as originating sites, and enable telehealth and RPM to be considered basic benefits in Medicare Advantage, without most of the Section 1834(m) restrictions.

Response

According to an Avalere study, the bill could save as much as $1.8 billion over the next ten years. The American Medical Association (AMA) has expressed its support for the bill, noting that it stands to strengthen physician-patient relationships and improve care access while maintaining patient safety. The bill was introduced by Senators Brian Schatz (D-Hawaii), Roger Wicker (R-Miss), Thad Cochran (R-Miss), Ben Cardin (D-Md), John Thune (R-SD), and Mark Warner (D-Va). The Senators praised the advances of health information technology and the promise of telehealth, noting the importance of the opportunity to bring together improvements in technology with the prospect of better care quality.

Information on geographic variation of utilization and quality updated

As part of its efforts to support data-driven decision making efforts, the Office of Enterprise Data and Analytics (OEDA) within CMS updated the Geographic Variation Public Use File (GV PUF) in January 2016. The GV PUF is based primarily on information from CMS’ Chronic Conditions Data Warehouse (CCW), which contains 100 percent of Medicare claims for beneficiaries who are enrolled in the fee-for-service (FFS) program as well as enrollment and eligibility data. The January 2016 update to the GV PUF includes data for 2007-2014 and incorporates minor revisions to the CMS methodology.

GV PUF

The GV PUF is made up of 12 separate files with data designed to enable researchers and policymakers to evaluate geographic variation in the utilization and quality of health care services for the Medicare FFS population. The individual files are available from the CMS Web site and contain data on demographic, spending, utilization, and quality indicators at the state level (including the District of Columbia, Puerto Rico, and the Virgin Islands), the hospital referral region (HRR) level, and the county level. The GV PUF was originally posted in July 2011 and updated in July 2012, January 2013, May 2013, December 2013, February 2015, and September 2015.

The 12 files

The GV PUF has two files with state and county-level data, four files with only state-level data, and six files with HRR-level data. The files are presented in “Table” and “Report” formats. The “Table” files present indicators for all states, counties, or HRRs, and can be exported from Excel to another data analysis program for additional analysis. The corresponding “Report” files allow users to compare a specific state, county, or HRR to national Medicare benchmarks. The state- and HRR-level data are presented for beneficiaries under the age of 65, beneficiaries that are 65 or older, and all beneficiaries who regardless of age. The county-level data are only available for all beneficiaries.

Revisions to CMS methodology

The January 2016 update eliminated disease prevalence measures because CMS separately publishes this information in the Chronic Conditions Public Use File. OEDA produces this information to provide researchers and policymakers a better understanding of the burden of chronic conditions among beneficiaries and the implications for our health care system.

The update also made minor changes to the suppression methodology to ensure that all products from OEDA are consistent. Information is now suppressed for areas with fewer than 11 beneficiaries. Counter or secondary suppression is applied in cases where only one geographic area is suppressed for primary reasons, e.g. one county in a state has between 1 and 11 beneficiaries. In these cases, the geographic area with the next smallest count of Medicare FFS beneficiaries is suppressed as well. Also, if one sub-group (e.g. age group) is suppressed, then the other sub-group is suppressed.

Highlight on Vermont: New all-payer model grows out of state Medicaid budget crisis

For months, Vermont has been struggling with how to pay for its Medicaid program as reported costs have far outstretched allotted budgets. Instead of reducing benefits for all of the newly insured enrollees in Vermont’s health care programs, Governor Peter Shumlin announced a new payment system entirely, one that he claims will transform its health care system from one that rewards fee-for-service, quantity-driven care to one that rewards quality-based care that focuses on keeping Vermonters healthy.

All payer model. This new all-payer model is described by Shumlin as an agreement between the state and CMS that enables the three main payers of health care in Vermont–Medicaid, Medicare, and commercial insurance—to pay for health care differently than the traditional fee-for-service reimbursement. In an all-payer model, Vermonters will continue to have the same choice of providers as they have today under Medicare, Medicaid, and commercial insurance. Benefits will not be reduced and by changing the payment structure, Medicare beneficiaries may have access to, and coverage for, new services not currently covered by Medicare.

In Vermont’s proposal, the all-payer model will require commercial insurers and Medicaid to pay the same way Medicare will be paying for health care under its Next Generation program. All involved payers will approach health care payment to accountable care organizations in a common way and all payers will provide doctors and other health care professionals the flexibility they need to lead health care delivery change. Maintaining the same set of rules, standards, and methods of payment across payers will drive efficiencies in the system. The all-payer model builds off current federal and state health care reform efforts that have value-based payment components.

Outlined to the public on January 25, 2016, Shumlin and the Green Mountain Care Board released an outline or term sheet detailing the new all-payer system. The state is focusing on three main health goals: increasing access to primary care, reducing the prevalence of chronic diseases, and addressing the substance abuse crisis. The term sheet lays out plans to curb expenses by setting a 3.5 percent spending target and 4.3 percent spending cap, with a commitment that “Medicare will grow more slowly in Vermont than nationally.” These financial targets, the term sheet notes, are based on health care services in Vermont’s Medicare, commercial, and Medicaid shared savings programs today, mostly hospital and physician services.

“From Day 1, reforming the way doctors and other medical providers are paid has been a priority of my administration,” Gov. Shumlin said. “This is the only way we will curb the rising cost of health care that gobbles up money faster than Vermonters can make it. Today is the beginning of the rubber hitting the road on cost containment. Our success will mean better health outcomes for Vermonters and the end to health care costs rising faster than our economic growth.”

Investments in infrastructure. To curb spending, Vermont is planning to incorporate old and new ways of making health care more affordable. By investing in the state’s current infrastructure, Shumlin plans to expand the Services and Supports at Home (SASH) program, which already has a track record of saving money while keeping seniors in their home and out of hospitals. Another program Vermont intends to continue with is Medicare participation in the Blueprint for Health, Vermont’s nationally recognized initiative transforming primary care, which has also already demonstrated success. The state also proposes to add Medicare participation in the Hub and Spoke opiate addiction treatment program.

The state is currently in the process of finalizing negotiations of the terms of the all-payer model with the federal government. The information and terms released by Vermont do not represent the final state plan.

Health care organizations team up to fight implied certification theory

A number of interested health care organizations have filed briefs before the U.S. Supreme Court in Universal Health Services v. U.S. ex rel. Escobar, in which the court will consider the theory of implied certification under the False Claims Act (FCA) (31 U.S.C. §3729). Under this theory, claims submitted to the government for reimbursement are tainted by failure to conform to statute, regulations, or provisions that are not considered a condition of payment (see Does fraud go without saying? Supreme Court to examine ‘implied certification’ in FCA, Health Law Daily, December 8, 2015).

Factual background

The case was brought by the parents of a patient who died at a mental health clinic following a seizure. The parents alleged that the caregivers were not supervised as required and that the clinic did not have psychiatrists and psychologists on staff with the credentials required by the state Medicaid program. They claimed that this noncompliance caused claims for payment to be false claims, even though payment was not conditioned upon meeting these particular regulations (see Appeals court takes practical approach to False Claims Act, Health Law Daily,  March 19, 2015).

Whistleblower suits

The health care organizations filing briefs in support of Universal Health Services, like the American Hospital Association, argue that the implied certification theory broadens the reach of the FCA beyond addressing truly fraudulent claims. The American Medical Association’s (AMA) brief notes the sharp increase in qui tam actions filed by relators hoping to obtain “life-changing wealth” by bringing fraud claims based on noncompliance with an underlying regulation, even when the government is satisfied with the original transaction. The organizations believe that the FCA should be used to fight fraud, and the AMA asserts that “imperfect compliance is not equivalent to fraud.”