RISE summarizes recent regulatory news.

CMS takes action to increase oversight, improve quality of nursing homes

The Centers for Medicare & Medicaid Services (CMS) announced it is increasing scrutiny and oversight over the country’s poorest-performing nursing facilities to immediately improve the care they deliver. The agency has made revisions to the Special Focus Facility (SFF) Program, toughening requirements for completion of the program and increase enforcement actions for facilities that fail to demonstrate improvement. CMS is also calling on states to consider a facility’s staffing level in determining which facilities enter the SFF Program.

The actions aim to help fulfil the Biden Administration’s plans to overhaul the SFF Program to strengthen scrutiny over more poor-performing nursing homes, improve care for the affected residents more quickly, and better hold facilities accountable for improper and unsafe care. Currently, 88 nursing homes participate in the SFF Program, approximately 0.5 percent of all nursing homes in the country.

“Let us be clear: we are cracking down on enforcement of our nation’s poorest-performing nursing homes,” HHS Secretary Xavier Becerra said in the announcement. “As President Biden directed, we are increasing scrutiny and taking aggressive action to ensure everyone living in nursing homes gets the high-quality care they deserve. We are demanding better because our seniors deserve better.”

The changes include:

Tougher requirement: CMS is adding a threshold that prevents a facility from exiting based on the total number of deficiencies cited—no more “graduating” from the program’s enhanced scrutiny without demonstrating systemic improvements in quality.

Federal funding termination: Funding will not be available to facilities that don’t improve. CMS considers all facilities cited with Immediate Jeopardy deficiencies on any two surveys while in the SFF Program for discretionary termination from the Medicare and/or Medicaid programs.

Increased enforcement: CMS will impose more severe, escalating enforcement remedies for SFF Program facilities that have continued noncompliance and little or no demonstrated effort to improve performance.

Sustainable improvements incentives: CMS will extend the monitoring period and maintain readiness to impose progressively severe enforcement actions against nursing homes whose performance declines after graduation from the SFF Program.

State requirement on staffing levels: CMS has advised State Survey Agencies to consider a facility’s staffing level, in addition to its compliance history, when selecting candidates from their state for inclusion in the SFF Program.

For more information, see the White House fact sheet.

ACHP non-profit plans represent one third of 5-Star plans in 2023

A new analysis by the Alliance of Community Health Plan (ACHP) finds that its members with Medicare Advantage (MA) plans outpaced competitors in Medicare Star ratings. More than one-third of all beneficiaries nationwide in 5-Star plans are enrolled with an ACHP member company—even though ACHP members represent approximately 10 percent of total Medicare Advantage enrollees.

RELATED: 2023 Medicare Advantage and Part D Star ratings are out: The gap widens between 5-Star and 2-Star plans

According to ACHP, its members excelled in key metrics for clinical measures and consumer experience. On average, ACHP member non-profit plans outscored the competition on 45 out of 50 measures, including managing chronic conditions, customer service, and rating of health plan. They also scored high on consumer retention. More than half of all ACHP member companies report 90 percent of enrollees stick with their MA plan year after year, outpacing the competition by more than 10 percent.

Overall, more than 60 percent of MA plans offered by ACHP member companies earned a 4.5 or higher from CMS.

“These scores are a result of community health plans’ unique approach to coverage and care,” ACHP President and CEO Ceci Connolly said in an announcement. “When payers and providers work together, they’re able to focus on consumers’ needs—ensuring better health outcomes and an overall better care experience. As we look ahead to the future of Medicare Advantage, ACHP and our members are committed to improving and modernizing the program to further demonstrate the positive impact payer-provider systems have on health outcomes.”

Americans may have trouble accessing treatment, testing with COVID-19 funding running out

A Kaiser Family Foundation (KFF) brief examines upcoming changes to the accessibility and cost of COVID-19 vaccines, treatments, and tests after the current government supply is depleted and the public health emergency (PHE) ends.

Regulatory update: HHS extends PHE again

The Biden Administration has announced that it will have to end its purchase and distribution of COVID supplies as government funding is depleted. Although Xavier Becerra, secretary of the Department of Health and Human Services (HHS), recently extended the PHE for another 90 days, industry experts expect it will end next year. The public health emergency was recently extended for 90 additional days but is expected to end next year. These developments signal a shift in the United States’ response to the pandemic and a transition from government-supplied countermeasures to the commercial market for manufacturing, procurement, and pricing, KFF said.

This transition to the commercial market could curtail access to vaccines (including boosters), treatments, and tests. Without the federal government’s guaranteed “market” for these products through their advance purchase, it is uncertain whether manufacturers will have an incentive to produce enough. Meanwhile, people with insurance could face new or higher cost-sharing for treatments and testing, depending on their coverage and the type of treatment or test they want to access. People who are uninsured and underinsured stand to lose the most, with limited access to free vaccines and no coverage for the cost of treatments and tests. And all Americans could face access challenges if sufficient supplies are not available from manufacturers or procured by pharmacies or other providers.

New West-Gallup poll: 1 in 3 Americans say health care in the US deserves an F for affordability

Forty-four percent, or about 114 million Americans, give poor (30 percent) or failing (14 percent) grades to the U.S. health care system, percentages that climb higher and grow even more negative when it comes to affordability and health equity, according to a recent report from West Health and Gallup, the polling organization.

The 2022 West Health-Gallup Healthcare in America Report asked a nationally representative sample of more than 5,500 Americans to provide a letter grade (A-F) for the health care system overall and to give individual grades for affordability, equity, accessibility, and quality of care. Among the key findings:

  • The health care system got an average grade of C-minus. Women and Hispanic and Asian Americans were more negative, with about half of each group assigning it a grade of D or F compared to about 40 percent of males and 43 percent of white and Black Americans.
  • Three-quarters of Americans (projecting to more than 190 million adults) gave affordability no higher than a D (41 percent) or F (33 percent) for an average grade of D-minus. The negative feelings about health care affordability were similar across gender, age, race, household income, and political persuasion.
  • Two-thirds of Black Americans (66 percent) and a similar percentage of Asian Americans (64 percent) gave a D or F for equity, the ability of every person to get quality care when they need it regardless of personal characteristics. That’s more than the 55 percent of Hispanic Americans and 53 percent of white Americans who deemed health equity to be poor or failing.
  • Black, Hispanic, and Asian Americans and women were more critical when it came to access to care. More than 40 percent of each of these groups gave access Ds and Fs, compared to about a third of white Americans and men.
  • Quality of care was the only aspect of the health care system that received more positive than negative marks, but it still earned an overall grade of C-plus. Less than half (47 percent) gave it an A or B grade, but a significant gender divide emerged, with women much less likely to give high grades for quality than men (38 percent vs. 57 percent). Black Americans and Hispanic Americans were also more negative on quality and less likely to give top marks than the general population (36 percent each vs. 47 percent overall).
  • Half the country, an estimated 129 million people, have low levels of confidence that they can afford health care as they age.
  • Two in three Americans under 65 are worried Medicare will not exist when they reach the age of eligibility, and three in four aged 62 or younger say the same about Social Security.