The Centers for Medicare & Medicaid Services (CMS) has developed a public use file that enables researchers and policymakers to evaluate geographic variation in the utilization and quality of health care services for the Medicare fee-for-service population. The Geographic Variation Public Use File includes demographic, spending, utilization, and quality indicators at the state level (including the District of Columbia, Puerto Rico, and the Virgin Islands), hospital referral region (HRR) level, and county level.
As prescription drug spend continues to be top of mind for healthcare purchasers, this week was timely for Magellan Rx Management to release its 92-page seventh annual Medical Pharmacy Trend Report, which this year highlighted "the member and payer impact of high-cost specialty drugs billed on the medical benefit..."
Drug Spend Trends Under The Medical Benefit
As prescription drug spend continues to be top of mind for healthcare purchasers, this week was timely for Magellan Rx Management to release its 92-page seventh annual Medical Pharmacy Trend Report, which this year highlighted "the member and payer impact of high-cost specialty drugs billed on the medical benefit,"
Magellan Rx Management Medical Pharmacy Trend Report
Tidbits from the report examining Rx costs and utilization covered under plan medical benefits, and rendered through medical pharmacies (home infusion/specialty pharmacy; hospital outpatient pharmacy or physician office) included:
Commercial pmpm Rx costs were $23.68 and Medicare Advantage Rx costs were $46.01
4% of Commercial members and 12% of Medicare Advantage members had a medical pharmacy claim
Commercial Rx spend increased by 12 % each year from 2011-2015,
Medicare Advantage Rx spend increased 5 % in total over the same five-year period.
Oncology and supportive care agents represent nearly 50% of commercial Rx spend
Oncology and supportive care agents represent nearly 60% of Medicare Advantage Rx spend
The 10 most expensive commercial drugs averaged $421,220 annually per patient
Commercial utilization for these 10 most expensive drugs was two per 100,000 members
The 10 costliest Medicare drugs averaged $268,780 annually per patient
Medicare utilization for these 10 costliest drugs was eight per 100,000 members
For the top 25 drugs, the avg. annual cost per patient was $24,751 for Commercial and $11,063 for MA
Consumer out of pocket costs averaged 3% for Commercial and 5% for Medicare Advantage
Magellan's recommended strategies for addressing these trends include: (1) Clinically and operationally managing drugs billed with unclassified Healthcare Common Procedure Coding System codes; (2) Improving claims system capabilities to capture and report National Drug Codes; (3) Employing provider network strategies for commercial members to remove disparities in cost by outpatient site of service; (4) Implementing benefit design strategies, and (5) Bringing transparency of medical benefit drug costs and therapeutic options to members.
For proponents of the American Health Care Act, perhaps the most encouraging nugget in the Congressional Budget Office’s otherwise critical analysis is that insurance premiums could fall by 10 percent on average by 2026. Even this prediction is more mirage than reality, however, in part because of an obscure concept known as “actuarial value.”
The American Health Care Act: the Republicans’ bill to replace Obamacare, explained
by Sarah Kliff
House Republicans released their long-awaited replacement plan for the Affordable Care Act on Monday.
The American Health Care Act was developed in conjunction with the White House and Senate Republicans. Two big questions — how many people it will cover and how much it will cost — are still unresolved: It will likely cover fewer people than the Affordable Care Act currently does, but we don’t know how many. And the Congressional Budget Office has not yet scored the legislation, so its price tag is unknown.
The Department of Health and Humans Services’ Office of the National Coordinator for Health Information Technology (ONC) announced the Phase 2 winners of the Move Health Data Forward Challenge.
Winning submissions will now move on to the challenge’s last phase to develop applications that will allow individuals to share their personal health information safely and securely with their health care providers, family members or other caregivers.
Phase 1 of the Move Health Data Forward Challenge required applicants to submit their plans describing how they would develop solutions to help with the flow of health information. The ten Phase 1 winners were awarded $5,000 each and moved on to Phase 2, which required participants to demonstrate a viable solution to achieve those goals by allowing for the safe and secure exchange of consumer or provider health records.
New Report Shows that Medicare Advantage Payments Won’t Keep Pace With Costs in 2018
by Kristine Grow
Payment cuts would threaten benefits and savings for more than 18 million seniors
Millions of seniors who depend on Medicare Advantage (MA) plans could see cuts to their coverage and benefits if new payment changes take effect next year. That’s according to a new analysis by Oliver Wyman prepared for America’s Health Insurance Plans (AHIP).
The Centers for Medicare & Medicaid Services (CMS) has updated its Medicare claims processing manual to include guidance on implementing the Medicare Outpatient Observation Notice (MOON), a standard notice that all hospitals and critical access hospitals must provide effective March 8 to all Medicare beneficiaries who receive outpatient observation services for more than 24 hours. Under the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act of 2015, hospitals must provide oral and written notice to beneficiaries within 36 hours after observation services are initiated, or sooner if the individual is transferred, discharged, or admitted as an inpatient. The notice informs patients they are an outpatient receiving observation services, not an inpatient, and about the associated implications for cost-sharing and eligibility for Medicare coverage of skilled nursing facility services. Among other things, the guidance addresses:
The scope of the requirements;
How hospitals must deliver the notice and within what timeframe;
Steps to take if a beneficiary refuses to sign the MOON, or if the notice must be delivered to a beneficiary’s representative;
Ensuring beneficiary comprehension;
What may be provided in the “additional information” field of the MOON;
Retention requirements for the MOON; and
The intersection with state laws on observation notices.
CMS issued the final policies for implementing the NOTICE Act last August with the inpatient prospective payment system final rule, but delayed implementation until 90 days after the updated MOON was posted.
News Item - 02/17/2017
National health expenditure growth is expected to average 5.6 percent annually over 2016-2025, according to a report authored by the Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary (OACT).
These projections are constructed using a current-law framework and do not assume potential legislative changes over the projection period.
National health spending growth is projected to outpace projected growth in Gross Domestic Product (GDP) by 1.2 percentage points. As a result, the report also projects the health share of GDP to rise from 17.8 percent in 2015 to 19.9 percent by 2025. Growth in national health expenditures over this period is largely influenced by projected faster growth in medical prices compared to recent historically low growth. This faster expected growth in prices is projected to be partially offset by slowing growth in the use and intensity of medical goods and services.
According to the report, for 2016, total health spending is projected to have reached nearly $3.4 trillion, a 4.8-percent increase from 2015. The report also found that by 2025, federal, state and local governments are projected to finance 47 percent of national health spending, a slight increase from 46 percent in 2015.
Additional findings from the report:
Total national health spending growth: Growth is projected to have been 4.8 percent in 2016, slower than the 5.8 percent growth in 2015, as a result of slower Medicaid and prescription drug spending growth. In 2017, total health spending is projected to grow by 5.4 percent, led by increases in private health insurance spending. National health expenditure growth is projected to be faster and average 5.8 percent for 2018-2025 largely due to expected faster spending growth in both Medicare and Medicaid.
Medicare: Medicare spending growth is projected to have been 5.0 percent in 2016 and is expected to average 7.1 percent over the full projection period 2016-2025. Faster expected growth after 2016 primarily reflects utilization of Medicare covered services increasing to approach rates closer to Medicare’s longer historical experience. This results in Medicare spending per beneficiary growth of 4.1 percent over 2016-2025 (compared to 1.6 percent growth for 2010-2015).
Private health insurance: Spending growth is projected to have slowed from 7.2 percent in 2015 to 5.9 percent in 2016, a trend that is related to slower growth in private health insurance enrollment. Spending growth is projected to increase to 6.5 percent in 2017, due in part to faster premium growth in Marketplace plans related to previous underpricing of premiums and the end of the temporary risk corridors.
Medicaid: Projected spending growth slowed significantly in 2016 to 3.7 percent, down from 9.7 percent in 2015, largely reflecting slower growth in Medicaid enrollment. Spending growth is expected to accelerate and average 5.7 percent for 2017-2025 as projected per-enrollee spending growth rises over that timeframe. Underlying the faster per enrollee growth is the increasingly larger share of the Medicaid population who are aged and disabled and who tend to use more intensive services.
Medical price inflation: Medical prices are expected to increase more rapidly after historically low growth in 2015 of 0.8 percent to nearly 3 percent by 2025. This faster projected growth in prices is influenced by an acceleration in both economy-wide prices and medical specific prices and is projected to be partially offset by slowing growth in the use and intensity of medical goods and services.
Prescription drug spending: Drug spending growth is projected to have been 5.0 percent in 2016, following growth of 9.0 percent in 2015, mainly due to slowing use of expensive drugs that treat Hepatitis C. Growth is projected to average 6.4 percent per year for 2017-2025, influenced by higher spending on expensive specialty drugs.
Insured Share of the Population: The proportion of the population with health insurance is projected to increase from 90.9 percent in 2015 to 91.5 percent in 2025.
Inpatient Hospitalization Costs Associated with Birth Defects Among Persons of All Ages — United States, 2013
by Annelise C. Arth, MPH; Sarah C. Tinker, PhD; Regina M. Simeone, MPH; Elizabeth C. Ailes, PhD; Janet D. Cragan, MD; Scott D. Grosse, PhD
In the United States, major structural or genetic birth defects affect approximately 3% of live births and are responsible for 20% of infant deaths. Birth defects can affect persons across their lifespan and are the cause of significant lifelong disabilities. CDC used the Healthcare Cost and Utilization Project (HCUP) 2013 National Inpatient Sample (NIS), a 20% stratified sample of discharges from nonfederal community hospitals, to estimate the annual cost of birth defect–associated hospitalizations in the United States, both for persons of all ages and by age group. Birth defect–associated hospitalizations had disproportionately high costs, accounting for 3.0% of all hospitalizations and 5.2% of total hospital costs. The estimated annual cost of birth defect–associated hospitalizations in the United States in 2013 was $22.9 billion. Estimates of the cost of birth defect–associated hospitalizations offer important information about the impact of birth defects among persons of all ages on the overall health care system and can be used to prioritize prevention, early detection, and care.
Longer lifespans largely not to blame for rising health care spending
by Austin Frakt
American life spans are rising, and as they are, health care spending is, too. But longevity is not contributing to the spending increase as much as you might think.
The median age in the United States will rise to about 40 by 2040, up from 37.7 today. That’s partly because the average American lives three years longer today — reaching nearly 79 years old — than in 1995. The Congressional Budget Office credits population aging for a substantial portion of its projected increase in health care spending — from 5.5 percent of the economy today to almost 9 percent by 2046.
Fiscal Year (FY) 2018 Medicare Hospital Inpatient Prospective Payment System (IPPS) and Long Term Acute Care Hospital (LTCH) Prospective Payment System Proposed Rule, and Request for Information CMS-1677-P
On April 14, 2017, the Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would update 2018 Medicare payment and polices when patients are admitted into hospitals. The proposed rule aims to relieve regulatory burdens for providers; supports the patient-doctor relationship in health care; and promotes transparency, flexibility, and innovation in the delivery of care.
Now that ICD-10 is in full swing, we are seeing a lot of activity with providers, payers, consultants and regulators who need to understand how Acute Inpatient and Long Term Care Hospital claims "behave" when the claim is coded in ICD-10. This includes both prospective and retrospective review of claims scenarios to understand MS-DRG grouping. This article offers a basic primer on MS-DRG grouping logic, and research techniques for using related MediRegs Coding Suite tools. If you'd like a personalized training on these tools, or a demonstration of them in action to see if they are a good fit for your research scenarios, please let us know!
OVERVIEW OF THE FY 2016 IPPS FINAL RULE: SUMMARY OF CALCULATION ELEMENTS
New Health Analytics, a national healthcare software developer and data analytics firm, is pleased to announce that it has released a special report with an concise review of the FY 2016 Hospital Inpatient Prospective Payment System (IPPS) Final Rule recently posted by the Centers for Medicare & Medicaid Services.