Managed Care Is Coming To Get You, Barbara…..

(Still, from “Night of the Living Dead,” courtesy Wiki Media Commons.)

 

Bill Myers

Hello, ProviderNation. The fine folks at CMS have released their annual guide to Medicaid managed care rates. There are few surprises in it (as far as this English major can tell), but what continues to fascinate Your Humble Correspondent is the speed—and silence—with which managed care has steadily risen from its grave and crept up on mainstream health care.

Recall the pitchfork-and-torches that were gathered in the late 1990s, as HMOs were pilloried from the Hill to Hollywood and back again. Now, however, managed care isn’t just a trend—it’s the norm in most states, and it has the warm (and continuing) endorsement of folks like MedPAC.

That doesn’t mean that providers have taken things lying down. Recall that, just a month or so ago, the biggest huzzahs from Provider’s inaugural Ignite panel came when an audience member gave a full-throated “get thee behind me, managed care” speech.

Wicked Pahty…

In happier news, mad props to the good people of the Massachusetts Senior Care Foundation, who recently celebrated their group’s 30^th anniversary—and who, oh, by the way, raised another $270,000 for the care of Massachusetts elders and adults with disabilities.

Since 1985, the foundation has handed out more than $2.7 million in 1,500 scholarships to long term care workers, sending them to (or back to) school to continue their educations.

Mark Parkinson, Alice Bonner, and Red Sox legend Luis Tiant were on hand, a reliable source tells me, and a good time was had by all.

NIC In Time…

Speaking of anniversaries and funky good times, the fine folks at NIC are hosting their 25^th annual convention right here in the D.C. area this week. They’ll be gathering at National Harbor with the theme, “With Changes, Come Opportunity.”

Your Humble Correspondent will be checking out all the white-hot, analyst-on-analyst action, and maybe even the odd live Tweet. Hope to see you there.

Bill Myers is Provider’s senior editor. Email him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

 

 

 

This is Our Concern, Dude….

U.S. Rep. Jim McDermott, D-Wash., is pressuring HHS officials to solve their administrative appeals crisis.

Good afternoon, ProviderNation.

U.S. Rep. Jim McDermott has some, um, questions about the monstrous backlog of health care appeals that has so, um, disconcerted folks lately.

In a “This is our concern, Dude,” letter to Health and Human Services Secretary Kathleen Sebelius, McDermott says he’s “troubled” that patients may be getting buried in paperwork and that the recovery auditors (RAs) themselves are “the proximate cause” of all this trouble.

The distinguished gentleman from the fine state of Washington (who also happens to be the ranking member on the Health subcommittee for House Ways & Means) says he hears that even though Medicare beneficiaries are supposed to be moved to the front of the line in all appeals, “because of the sheer number of appeals, some beneficiaries are even having troubling having their appeals heard.”

This, as everyone’s favorite medievalist might say, is intolerable.

But the real target of McDermott’s letter appears to be the RAs themselves. He says that the government can save itself a lot of trouble “without any intervention by Congress” by, among other things:

1.)    Changing the “two midnights” policy. McDermott has been on this before, and he says the policy is “flawed and unworkable.” He adds that “the underlying issue that is driving the need for more concrete admission standards” is the RA program, which McDermott says “should be re-examined and modified.”

“I know that CMS has limited the ability of RAs to review claims under this policy while the policy is adjusted but I note that Medicare Administrative Contractors (MACs) are able to deny improper claims that they identify as part of the probe and educate reviews,” McDermott says. “I continue to have serious reservations about this policy and believe that it will only exacerbate the appeals backlog. Because important issues such as these are not well understood, I ask that you reconsider whether this policy is ready for enforcement—even limited enforcement through probe and educate reviews.”

2.)    Adding “enhanced accountability” for the auditors. McDermott says he’s worried that the auditors seem to be playing with house money—even if they lose on appeal. “I suggest that there needs to be some financial penalty associated with RA collections that are overturned on appeal,” he says. “If providers are winning these appeals by large margins, which seems to be the case, this seems only fair.” And finally, the government should make sure that …(see #3).

3.)    The new “pause” in audits actually “addresses the problem,” McDermott says. “I suggest that the pause be continued until relevant parties are certain they have a plan in place to (a) make appropriate modifications to the RA program and (b) address the existing backlog of appeals,” he says. “In addition, you might consider limiting the lookback period associated with claims submitted during the pause.”

Bill Myers is Provider’s senior editor. E-mail him at wmyers@providermagazine.com. Follow him on Twitter, @ProviderMyers.

Send Lawyers, Guns and Money…

“Our serious concerns remain,” Parkinson says of the HHS audit appeal backlog.

Good afternoon, ProviderNation.

HHS had its party and everyone was invited. But it was hardly the social event of the season.

The fab forum on the agency’s awful backlog of audit appeals went down yesterday. Advocates say they haven’t heard what they needed to hear.

“Unless policy and process improvements are introduced soon,” AHCA honcho Mark Parkinson says, “the appeals process will become even more dysfunctional.”

According to a couple of participating informants, HHS types repeated complaints about their workload (350,000 cases and counting) but, looking on the bright side, they said they’ve increased productivity (raising their decisions per day from 2.2 in 2009 to 4.9 per day last year).

If that didn’t win the audience over, HHS types made it even worse by claiming the freeze in new appeals wasn’t “a moratorium,” but a “deferred assignment” process.  Our participating informants heard that as, “Send Lawyers, Guns and Money.”

HHS officials are promising that they’ll open a new regional office somewhere in America’s middle and draw up a new manual with “best practices.” They’ll also use voluntary statistical sampling, and offer mediation.

Finally, HHS says there will be a new rulemaking notice offering the public a chance to offer comments and suggestions. So you got that going for you, which is nice.

Parkinson says his group “applauds” HHS officials “for this effort and will make every attempt to work with HHS on this process.”

But he adds that there must needs “be fewer inaccurate Medicare contractor audits” or more money and time spent on the casework.

“Something must change to permit timely and appropriate initial claim processing and early appeal decisions,” Parkinson says. “If not, the backlog could cause disruptions to beneficiary access to health care, especially to nursing and therapy services.”

Bill Myers is Provider’s Senior Editor.

Thoughts on Thinking…

Good morning, ProviderNation.

On Monday, we brought you a scintillating write-up on a new study attacking the “myth” of cognitive decline.

The short version is that the research team, led by German cognitive scientist Michael Ramscar, believes that seniors are getting a bum rap.

Michael Ramscar

Ramscar and his self-described “henchmen” say that seniors may take longer to recall words or names in various tests, but that’s merely a function of how much knowledge they’ve absorbed over the course of their long lives. They take things a step further, by arguing that we can’t assume a senior is in “cognitive decline” unless she has been diagnosed with a recognized pathology (Alzheimer’s, etc.)

We weren’t the only ones to have noticed Ramscar’s work. In fact, it’s generated such international interest that Ramscar has started a separate blog about it.

The team’s full study is here. It’s worth reading for a couple of reasons. First, Ramscar writes brilliantly and clearly (so even folks as slow as Your Humble Correspondent can understand him). Second, his research has lots of implications for providers—especially those who want to focus on person-centered care.

If Ramscar and his team are right, for instance, about discriminative learning (check, especially, the bit about discriminative learning being context-driven—viz., retirement), that means that those who watch their grandmother struggle to recall a former boyfriend’s name (say) and assume they’re watching a mind in decline aren’t just being lazy, they’re throwing away a pearl richer than their tribe.

It’s Never Too Late

Head abuzz about all this, I talked with my own personal tech guru, Jack York. Jack runs a company that sells software apps to nursing homes in order to help residents reconnect with family, friends, and their pasts. (Call him a biased source, if you like,but he’s so turned on by New Ideas and Big Ideas that an hour with him feels like a philosophy symposium.)

Less concerned about the science, Jack says he’s already a step ahead of Ramscar and his team, because even pathologies such as Alzheimer’s may be disguising a rich intelligence (and life).

“The debate over brain fitness has been ongoing for quite a few years,” he tells me in an email. “My own editorial commentary, after providing technology to nursing home residents for over 15 years, is that the obsession over brain ‘improvement,’ often misses the point. I feel the goal to strive for is to improve people’s quality of life.”

Naturally, Jack’s a technocrat here. But, statements against interest: One of his favorite videos shows a woman in rehabwho, initially defiant, logs on to Google Earth (not a Jack York product) to see the Jersey beach house where she used to summer. You can watch the results here.

“If we remain obsessed with showing ‘improvement’ (that may or may not be even be agreed to),” Jack tells me, “then the 94-year-old with late-stage dementia will be left out of experiences that can dramatically improve the sunset of her life.”

Cav Id Therapy Caps…

Good morning, ProviderNation.

Providers will have to caveat their emptori from now. The good people over at CMS have issued a memo that they hope will clarify the Advance Beneficiary Notice of Noncoverage (ABNs) requirements of the American Taxpayer Relief Act.

In the good ole days of say, Dec. 31, 2012, providers were merely “encouraged” by CMS to warn patients that there were therapy caps and all that.

Were we ever that young?

“Now the provider/supplier must issue a valid, mandatory ABN to the beneficiary before providing services above the cap when the therapy coverage exceptions process isn’t applicable,” CMS says in the memo.

We’ve got a scintillating write-up with more specifics here.

We’re No. 1…

Good afternoon, ProviderNation.

Huzzahs to the fine folks at FutureCare, who’ve just seen their outfit named as one of the nation’s best places to work by WorkPlaceDynamics and The Baltimore Sun. (That’s your cue, Freddie…)

Staff nominated FutureCare and filled in more than 500 questionnaires to make the cut, and company President and CEO Gary Attman says he and the team “are humbled to be considered in a class of employers, which include so many other great locally based—and in many cased multinational—companies.” Overall, FutureCare came in 30^th nationwide and was the top big employer in Maryland, according to the Sun’s list.

This award is an answer to those worry-warts who fret about the long term care profession’s future, Attman says. “We are also pleased that we are playing a role in changing the outmoded perception of skilled nursing facilities,” he says. “This award accurately reflects the incredible career opportunities for growth and satisfaction that skilled nursing facilities can provide.  And we are certain that there is a correlation between happy employees and happy patients and families, so this recognition is consistent with our goal of providing the very best patient care.”