RISE summarizes recent regulatory-related headlines.
CMS: 3 initiatives will help drive Medicare ACO participation
The Centers for Medicare & Medicaid Services (CMS) said Tuesday that three accountable care initiatives will grow and provide care to more than 13.2 million people with Medicare in 2023. Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers who collaborate to provide coordinated, high-quality care to their Medicare patients. The focus of this coordinated care is to ensure that patients get the right care at the right time, avoid unnecessary duplication of services, and prevent medical errors.
More than 700,00 health care providers will participate in at least one of the three initiatives–the Medicare Shared Savings Program (MSSP) and two CMS Innovation Center accountable care model tests. This growth will help achieve CMS’ goal of having all people with Traditional Medicare in an accountable care relationship with their health care provider by 2030. In addition to MSSP, the CMS accountable care initiatives include the Accountable Care Organization Realizing Equity, Access, and Community Health (ACO REACH) Model and the Kidney Care Choices (KCC) Model.
MSSP is the largest accountable care initiative in the country and is a permanent program in Medicare that was established by the Affordable Care Act. The program has 456 ACOs and 10.9 million assigned beneficiaries in 2023. While MSSP experienced a decrease in the number of ACOs and assigned beneficiaries for 2023, CMS said the policies finalized in the CY 2023 Medicare Physician Fee Schedule final rule will grow participation in the program for 2024 and beyond, when many of the new policies are set to go into effect. CMS expects these policies to drive growth in participation, particularly in rural and underserved areas, promote equity, and advance alignment across the accountable care initiatives, and increase the number of beneficiaries assigned to ACOs participating in the program by up to four million over the next several years.
The ACO REACH Model aims to improve the quality of care for people with Traditional Medicare through better care coordination and by increasing access to accountable care in underserved communities. The model will test benchmark adjustments to shift payments to better support care for the underserved and enhanced Medicare benefits, including care in the home. For 2023 the ACO REACH Model has 132 ACOs with 131,772 health care providers and organizations, providing care to an estimated 2.1 million beneficiaries. In addition, the model will have 824 federally qualified health centers, rural health centers, and critical access hospitals participating in 2023–more than twice the number in 2022. CMS said Increasing the number and reach of ACOs in underserved communities will help close racial and ethnic disparities that have been identified among people with traditional Medicare in accountable care relationships.
The KCC Model focuses on coordinating care for Medicare beneficiaries with chronic kidney disease stages four and five and end-stage renal disease. In addition to care coordination, the KCC Model focuses on key areas of concern for this population, including delaying the onset of dialysis and increasing access to kidney transplantation so more patients can live fuller and longer lives. For 2023, the model will include 130 KCC entities, which are accountable for the quality and care of their aligned beneficiaries. The KCC Model will have more than 8,398 participating health care providers and organizations and 249,983 beneficiaries in 2023, an 87 percent increase in the number of providers and organizations, a 62 percent increase in the number of beneficiaries from 2022, and the second cohort of the KCC Model increases the geographic reach of the Model into new areas, including North Dakota and South Dakota.
HHS report shows health coverage gains among underserved populations from 2019 to 2021
A new Department of Health and Human Services (HHS) report shows links between the Biden administration’s policies to large gains in health insurance coverage of Americans between 2019 and 2021. The report, from the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE), shows that larger gains in coverage occurred for demographic groups with higher historical uninsured rates, including younger adults, Latino individuals, American Indian/Alaska Native, and non-English speaking adults. Among the findings:
- Nationally, the uninsured rate for people under age 65 fell from 11.1 percent in 2019 to 10.5 percent in 2021.
- The decline in the uninsured rate was largest for those with household incomes between 100 and 250 percent of the Federal Poverty Level.
- Coverage gains varied widely across Asian American and Native Hawaiian/Pacific Islander and Latino communities; disaggregating data for these groups reveals important differences in coverage patterns.
- Federal policies–such as an enhanced Marketplace access to a Special Enrollment Period in 2021, expanded and enhanced premium tax credits under the American Rescue Plan, enhanced funding for Marketplace outreach and enrollment assistance, and the Medicaid continuous enrollment provision during the COVID public health emergency–likely contributed to gains in health coverage since 2019, particularly among low-income populations and communities of color.
CMS to increase oversight of antipsychotics use in nursing homes
CMS announced new actions it will take to reduce the inappropriate use of antipsychotic medications and to bring greater transparency about nursing home citations to families. Antipsychotic medications are especially dangerous among the nursing home population due to their potential devastating side effects, including death. The action plan includes targeted, off-site audits and publicly displaying survey citations that facilities are disputing.
“We have made significant progress in decreasing the inappropriate use of antipsychotic medications in nursing homes, but more needs to be done,” said CMS Administrator Chiquita Brooks-LaSure in the news announcement. “People in nursing homes deserve safe, high-quality care, and we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications.”
Beginning this month, CMS will conduct audits to determine whether nursing homes are accurately assessing and coding individuals with a schizophrenia diagnosis. CMS said nursing home residents erroneously diagnosed with schizophrenia are at risk of poor care and prescribed inappropriate antipsychotic medication. The new step to post citations under dispute aims to increase the transparency of nursing home information. Until now, when a facility disputes a survey deficiency, the deficiency is not posted to Care Compare until the dispute process is complete. CMS acknowledged the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance, such as immediate jeopardy citations which indicates residents could be at risk for serious injury, harm, impairment, or death. CMS said displaying this information while under dispute can help consumers make informed choices when evaluating facilities.
OIG: COVID findings show better protections are needed in nursing homes for future emergencies
A new report from the Office of Inspector General (OIG) examines the number of residents who were diagnosed with COVID-19 and the characteristics of nursing homes with extremely high infection rates. This is the second of a three-part series that the OIG conducted about the nursing home experience during 2020. The first report found that two in five Medicare beneficiaries in nursing homes either had or likely had COVID-19 in 2020. Those at greatest risk included Black, Hispanic, and Asian beneficiaries.
The latest report examined 15,086 nursing homes nationwide to determine nursing homes with extremely high infection rates during the surges of cases during the spring and fall of 2020. These homes had three-quarters or more of their Medicare beneficiaries diagnosed with COVID-19 or likely COVID-19 during a surge period. OIG looked at the characteristics of these nursing homes, whether they had been cited with any infection control deficiencies, and whether their reported nursing hours met minimum Medicare requirements for these hours.
The OIG found that more than 1,300 nursing homes had extremely high infection rates—75 percent or more of their Medicare beneficiaries—during these surges. These nursing homes were more common and geographically widespread during the second surge. Nursing homes with extremely high infection rates experienced dramatic increases in overall mortality (not limited to deaths of beneficiaries who had or likely had COVID-19). Specifically, these nursing homes experienced an average overall mortality rate approaching 20 percent during these surges—roughly double the mortality rate of other nursing homes during the same time periods. For comparison, in 2019 the average mortality rate in these same nursing homes was six percent. For-profit nursing homes made up a disproportionate percentage of the nursing homes with extremely high infection rates during both surges. Other characteristics varied by surge. For example, urban nursing homes were more likely to have extremely high infection rates during the first surge, but rural nursing homes were more likely to have extremely high rates during the second surge.
High COVID-19 transmission in a county did not always lead to nursing homes in that county reaching extremely high infection rates. In addition, the survey process did not identify any deficiencies in infection control for most nursing homes with extremely high infection rates, raising questions about how effective the survey process is in preventing and mitigating the spread of infectious disease in nursing homes. Also, most nursing homes with extremely high infection rates reported nursing hours that met or exceeded Medicare's specific minimum requirements for these hours, which may indicate that these requirements are not adequate to keep residents safe from infectious disease.
As a result of the findings, OIG said it’s clear that nursing homes in the U.S. weren’t prepared for the sweeping health emergency that COVID-19 created, nor were they able to stem the devastation once it was evident that nursing homes were especially vulnerable. The OIG recommends CMS take the following actions:
- Reexamine current nursing staff requirements and revise them as necessary
- Improve how surveys identify infection control risks to nursing home residents and strengthen guidance on assessing the scope and severity of those risks
- Target nursing homes in most need of infection control intervention and provide enhanced oversight and technical assistance to these facilities as appropriate
CMS concurred with the intent of the first and third recommendations and neither agreed nor disagreed with the second recommendation.
KFF: Medicaid expansion improves financial performance of hospitals
A new Kaiser Family Foundation (KFF) analysis, the latest installment in the non-profit organization’s ongoing effort to document what the research shows about the effects of Medicaid expansion, reveals the economic impact of Medicaid expansion on providers. The report summarizes 24 studies published between April 2021 and December 2022 and the findings are consistent with previous research in this area.
The analysis finds that Medicaid expansion has been beneficial to the finances of hospitals and providers, driving decreases in the share of uninsured patients, increases in Medicaid-covered patients, and declines in uncompensated care.
By financing coverage for low-income people who are likely to otherwise be uninsured, Medicaid expansion provides potential economic benefits to the health care providers who provide care to that population. Studies suggest that hospitals experienced higher reimbursements and decreased uncompensated care costs. Studies also find that other providers, including federally qualified health centers and community health centers, experienced increased revenue following expansion.
Some studies find that these economic effects vary by provider type. For example, a few studies find that despite declines in uncompensated care costs, improvements in financial performance were stronger for (or only observed among) rural and small hospitals. A small number of studies suggest that improvements in payer mix and uncompensated care costs at hospitals may have been partially offset by increases in unreimbursed Medicaid care and declines in commercial revenue.
The findings are particularly relevant given the fiscal stress experienced by Medicaid providers during the coronavirus pandemic, including recent challenges for hospitals as federal relief funds expire, KFF said. The research also provides context for ongoing policy debates about whether to expand Medicaid in states that have not done so already. State costs also remain a key issue in expansion debates.
Thirty-nine states plus Washington D.C. have adopted Medicaid expansion under the ACA, with the federal government covering 90 percent of the cost and states covering 10 percent. Eleven states have not adopted the Medicaid expansion. Prior KFF reports published in 2020 and 2021 reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers.