Podcasts about medicare medicaid services cms

Physician's Guide to Doctoring

Play Episode Listen Later Jan 13, 2025 7:29

This Day in Legal History: Wilder Elected First Black GovernorOn January 13, 1990, Lawrence Douglas Wilder made history by becoming the first African American elected governor of a U.S. state, taking office as the 66th governor of Virginia. Sworn in by former U.S. Supreme Court Justice Lewis F. Powell Jr., Wilder's inauguration symbolized a milestone in American political and civil rights history. His election represented the culmination of decades of progress in dismantling racial barriers, particularly poignant in Virginia, a state with a complex history as the capital of the Confederacy during the Civil War. Wilder, a Democrat, had previously served as the lieutenant governor of Virginia from 1986 to 1990, and earlier in the Virginia State Senate, where he was known for his advocacy for civil rights, education, and criminal justice reform. His gubernatorial campaign focused on pragmatic leadership, fiscal responsibility, and bridging divides in a state still grappling with its historical legacies of segregation and inequality. Wilder's narrow victory highlighted the increasing political influence of African Americans in the U.S. and underscored the potential for diverse representation at the highest levels of government.During his tenure, Wilder prioritized issues such as improving public education, reducing the state budget deficit, and enacting stricter gun control measures. Following his time as governor, he continued to serve the public as the mayor of Richmond from 2005 to 2009, further solidifying his legacy as a trailblazer and dedicated public servant. Wilder's career remains a testament to the possibilities of progress and a reflection of the changing political and social landscape of the United States.The U.S. Supreme Court is considering a case involving a law that requires TikTok's Chinese parent company, ByteDance, to sell the platform or face a U.S. ban, with a compliance deadline of January 19, 2025. TikTok's lawyer, Noel Francisco, warned that endorsing such a law could set a precedent allowing Congress to target other companies on similar grounds, potentially infringing on First Amendment protections. Francisco cited examples like AMC Theaters, which was once owned by a Chinese company, to illustrate the broader implications. The law was passed with bipartisan support due to concerns over national security, with lawmakers fearing the Chinese government could use TikTok to spy on Americans or spread propaganda. TikTok content creators, represented by lawyer Jeffrey Fisher, argued the law unfairly singles out TikTok while ignoring other Chinese-owned platforms like Temu, which also collect U.S. user data. Solicitor General Elizabeth Prelogar, representing the Biden administration, defended the law, stating it is essential to push ByteDance toward divestiture to mitigate risks from foreign adversaries. If implemented, the ban would prevent new downloads of TikTok, leading to the app's eventual obsolescence. The justices appeared divided, balancing national security concerns with constitutional protections of free speech. Former President Donald Trump has urged the court to delay the deadline until his administration, beginning January 20, could pursue a political resolution.TikTok warns of broad consequences if Supreme Court allows ban | ReutersU.S. Special Counsel Jack Smith, who prosecuted federal cases against Donald Trump for attempting to overturn the 2020 election and mishandling classified documents, has resigned from the Department of Justice. His resignation, effective January 10, 2025, follows Trump's victory in the 2024 election, which made the continuation of these cases against the president-elect untenable due to DOJ rules prohibiting the prosecution of a sitting president. Smith's cases were already hindered by legal setbacks, including rulings granting Trump broad immunity for actions taken as president.Smith submitted his final confidential report on January 7 and defended the merits of his prosecutions while requesting dismissal of the charges. His work led to historic firsts, as Trump became the first former U.S. president federally indicted, accused of retaining classified national security documents and attempting to disrupt the certification of the 2020 election. Both cases, however, faced legal delays, with one dismissed by a Trump-appointed judge and the other paused due to Supreme Court rulings on presidential immunity.Trump criticized Smith's investigations as politically motivated and pledged to dismiss him upon taking office. Smith's tenure included significant legal challenges, culminating in the decision to halt prosecutions against Trump while continuing efforts against associates involved in obstruction. Other legal cases, such as the Georgia election interference case, remain stalled or unresolved. Smith's resignation marks the end of his role in a polarizing chapter of U.S. legal and political history.Trump prosecutor Jack Smith resigns from Justice Department | ReutersApple is defending itself against a £1.5 billion ($1.8 billion) class-action lawsuit in the UK, which alleges the company abused its dominance by charging a 30% commission on App Store transactions, unfairly inflating costs for approximately 20 million iPhone and iPad users. The lawsuit, led by British academic Rachael Kent, claims Apple maintains a monopoly over app distribution and imposes restrictive terms that harm developers and consumers alike. Apple argues the case lacks merit, emphasizing that most developers pay no commission and highlighting the benefits of its iOS ecosystem, which prioritizes security and innovation. The company further defends its practices as a legitimate use of its intellectual property, dismissing allegations as an attempt to undermine its rights.This is the first large-scale lawsuit against a tech giant to go to trial under the UK's new class-action regime, with additional cases targeting Apple, Google, Meta, and Amazon expected to follow. A similar $1.1 billion case against Google over Play Store fees is set for later in 2025. The trial will last seven weeks, with Apple's CFO, Kevan Parekh, scheduled to provide testimony.Apple fights $1.8 billion App Store lawsuit in first of UK class actions against tech giants | ReutersThe Biden administration's negotiation of Medicare drug prices under the Inflation Reduction Act revealed the strategic approaches taken by both the Centers for Medicare & Medicaid Services (CMS) and pharmaceutical companies. These closed-door negotiations included legal, commercial, and policy experts on both sides, reflecting the complexity of determining prices for some of Medicare's most expensive drugs. The finalized cuts, announced in August 2024, ranged from 38% to 79%, aiming to generate billions in savings. However, skepticism remains over whether these savings will fully materialize due to offsetting factors.Pharmaceutical companies tailored their delegations to include experts in market access, global pricing, health economics, and portfolio strategy, reflecting their varied priorities. AstraZeneca, for example, sent contract operations specialists as part of its broader lawsuit challenging the program's implementation. Meanwhile, Novartis focused on market access for its heart failure drug, Entresto, expressing concerns about reduced patient access. Other companies, including Merck and AbbVie, redacted participant details, citing proprietary considerations.Legal teams were present at nearly every meeting, underscoring ongoing litigation over the program's constitutionality. Manufacturers have largely been unsuccessful in court, although some have won partial victories. Topics discussed during negotiations, such as clinical value and FDA approvals, offered insights into how both sides justified price cuts. The CMS plans to expand the program with additional drugs in its next negotiation round, which will occur under the incoming Trump administration. President-elect Trump has appointed Mehmet Oz to lead the CMS, signaling potential shifts in how the program is managed. Industry observers see these initial negotiations as a test case for broader reforms in U.S. drug pricing policy.Drug Industry Lawyers, Experts Helped Shape US Drug Price Cuts This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.minimumcomp.com/subscribe

#420 - Healthcare Under Trump 2.0: Policies, Predictions, and Preparations with Adam Block, PhD

Play Episode Listen Later Dec 17, 2024 27:25

Ready to diversify outside the stock market? EquityMultiple brings you streamlined real estate investing. Access vetted, cash-flowing opportunities from anywhere. Start today, with just $5K, at equitymultiple.com________What does the future hold for U.S. healthcare? In this podcast episode, Dr. Bradley Block interviews Adam Block, an associate professor of health policy at New York Medical College, to discuss the potential future of U.S. healthcare under the Trump administration.Key topics include the possible introduction of Medicaid block grants and work requirements—policies aimed at reducing state healthcare spending but potentially increasing administrative challenges. Adam Block predicts the continuation of popular programs like Medicare Advantage and telemedicine while raising concerns about controversial leadership appointments, such as Robert F. Kennedy Jr. at the U.S. Department of Health and Human Services.The conversation covers important topics like lowering drug prices, improving healthcare in rural areas, and the ongoing debate over whether private companies or the government run healthcare better. Dr Adam Block also looks back at how the COVID-19 pandemic was handled, pointing out what could have been done better and why being prepared is so important.He stresses the need for quick action on new healthcare laws at the start of a new administration, as there's only a short time to make big changes before political priorities shift.Bio.Adam Block is an associate professor of health policy at New York Medical College and a seasoned expert in health economics. He is the founder and CEO of Charm Economics, a boutique consulting firm specializing in economic modeling for digital health and medical technology companies, as well as assisting with legal damage estimation.His career includes serving as the director of strategic planning at Montefiore Medical Center in the Bronx and as the director of medical economics at Fidelis Care, New York's largest Medicaid plan. Notably, Adam spent five years contributing to the development of the Affordable Care Act and later worked as a regulator at the Centers for Medicare & Medicaid Services (CMS).Website:https://www.charmeconomics.com/Socials:LinkedIn: https://www.linkedin.com/in/adameblock/ _________Dr. Bradley Blocks' BioFind more about Dr. Block here: https://www.physiciansguidetodoctoring.com/mediaDid you know… You can also be a guest on our show? Please email me at brad@physiciansguidetodoctoring.com to connect or visit www.physiciansguidetodoctoring.com to learn more about the show!Socials:@physiciansguidetodoctoring on FB @physicianguidetodoctoring on YouTube@physiciansguide on Instagram and Twitter Visit www.physiciansguidetodoctoring.com to connect, dive deeper, and keep the conversation going. Let's grow! Disclaimer:This podcast is for informational purposes only and is not a substitute for professional medical, financial, or legal advice. Always consult a qualified professional for personalized guidance.

Episode 87 – Drug Pricing: What's In the New CMS Medicaid Final Rule?

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Play Episode Listen Later Nov 25, 2024 28:38

The Centers for Medicare & Medicaid Services (CMS) recently published its final rule to implement the Medicaid Services Investment and Accountability Act of 2019 (MSIAA). The final rule significantly deviates from the agency's 2023 proposal, with CMS backing off from “follow the pill” best price stacking, subjecting certain vaccines to Medicaid rebates, and creating a “shame list” of high-cost Medicaid drugs, among other proposals. But the final rule still imposes new burdens on manufacturers, such as by expanding which type of utilization triggers a Medicaid rebate, and imposing aggressive compliance deadlines in connection with misclassifications. In this episode of Connected With Latham, Washington, D.C. partner Chris Schott and associate Danny Machado break down what CMS included — and omitted — from its final rule. They also speculate about the impact the Supreme Court's overturning of the Chevron doctrine might have had on CMS' regulatory decision-making, as well as why the final rule's effective date is 60 days before the next presidential inauguration. This podcast is provided as a service of Latham & Watkins LLP. Listening to this podcast does not create an attorney client relationship between you and Latham & Watkins LLP, and you should not send confidential information to Latham & Watkins LLP. While we make every effort to assure that the content of this podcast is accurate, comprehensive, and current, we do not warrant or guarantee any of those things and you may not rely on this podcast as a substitute for legal research and/or consulting a qualified attorney. Listening to this podcast is not a substitute for engaging a lawyer to advise on your individual needs. Should you require legal advice on the issues covered in this podcast, please consult a qualified attorney. Under New York's Code of Professional Responsibility, portions of this communication contain attorney advertising. Prior results do not guarantee a similar outcome. Results depend upon a variety of factors unique to each representation. Please direct all inquiries regarding the conduct of Latham and Watkins attorneys under New York's Disciplinary Rules to Latham & Watkins LLP, 1271 Avenue of the Americas, New York, NY 10020, Phone: 1.212.906.1200

Therapy Cafe - Healing Together: The Impact of Integrated Care on Mental Health Outcomes

Future Of Mental Health

Play Episode Listen Later Nov 21, 2024 64:13

More than one-third of adults in the U.S. report experiencing a mental health condition or substance use disorder, yet less than half receive the treatment they need due to provider shortages, high costs, and gaps in coverage. Many individuals with behavioral health needs initially seek help in emergency departments or primary care settings, often leaving without proper treatment. To address this gap, the Centers for Medicare & Medicaid Services (CMS) launched the Making Care Primary (MCP) Model in 2023, focusing on innovative solutions in eight states. A key element of this initiative is the collaborative care model—a proven, evidence-based approach that integrates behavioral health into primary care to enhance access, outcomes, and patient satisfaction. Despite its strong track record, adoption remains limited due to reimbursement and scalability challenges. In the last episode of this season of Therapy Cafe, join host and Psych Hub co-founder Marjorie Morrison, LMFT, LPCC, and Dr. Caroline Carney, President of Behavioral Health and Chief Medical Officer at Magellan Health, as they explore the principles of integrated care, delve into the collaborative care model, and examine how measurement-informed care can drive better outcomes. This episode is a must-listen for therapists and mental health professionals interested in how they can be a part of the solution to streamline care delivery, improve patient outcomes, and expand their impact within integrated health systems. Key Learning Objectives: Describe the concept and benefits of integrated care Explain the collaborative care model, including the key providers required Examine the value of measurement-informed care If you'd like to obtain continuing education as a psychologist, counselor, social worker, or therapist you can purchase a one-year subscription to Psych Hub's training center. Once signed up, you'll have access to earn CEs for this and every Therapy Cafe episode, plus access to our existing library of over 120 evidence-based practice continuing education courses created by expert clinicians. Go to psychhub.com/signup for more information. Connect with Dr. Carney: https://www.linkedin.com/in/drccarney/ Learn more about the collaborative care work at Magellan: https://www.linkedin.com/company/magellan-health/ References: https://www.thenationalcouncil.org/resources/2022-access-to-care-survey-results/ https://www.cdc.gov/nchs/products/databriefs/db426.htm https://www.cms.gov/priorities/innovation/mcp/faqs

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Preparing for CMS Staffing Mandates

Troutman Pepper Podcasts

Play Episode Listen Later Nov 21, 2024 24:56

Assisted Living and the Law, hosted by Troutman Pepper attorneys Cal Stein and Emma Trivax, offers timely insights and practical advice on navigating the complex and evolving legal landscape of the long-term care industry.In this installment, Cal and Emma dive into the staffing mandates issued by the Centers for Medicare & Medicaid Services (CMS). They discuss the background and specifics of these mandates, including the required hours per resident per day (HPRD) nursing staff levels and the 24/7 registered nurse requirement. The episode also explores the potential challenges these mandates present for long-term care facilities, such as hiring and retention difficulties, increased operational costs, and the impact on patient care. Additionally, they offer practical risk mitigation strategies to help facilities navigate these new requirements effectively.

CMS Report: Acute Hospital Care at Home Program

McDermott+Consulting

Play Episode Listen Later Oct 10, 2024 10:03

Leigh Feldman joins Julia Grabo to discuss the recent Centers for Medicare & Medicaid Services (CMS) report on the Acute Hospital Care at Home program, including patient characteristics and satisfaction, quality of care, Medicare spending and utilization, and the program's future prospects.

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Episode 83 – Drug Pricing: How Are Payers Responding to the IRA?

Play Episode Listen Later Aug 19, 2024 29:16

The US healthcare landscape is undergoing significant changes as the Centers for Medicare & Medicaid Services (CMS) continues to implement the Inflation Reduction Act (IRA). One key stakeholder group affected by the IRA drug price negotiations and Medicare Part D redesign are health insurance companies. In this episode of Connected with Latham, we delve into how these payers are responding to the IRA, including the new ability for Part D beneficiaries to spread their cost-sharing equally across the plan year. Amanda Forys from Magnolia Market Access joins Washington, D.C. partner Chris Schott and associate Danny Machado to discuss the findings of a recent survey on payer trends. Beyond discussing the broader effects of the IRA on the healthcare industry, the conversation also touches on possible Part D premium increases and how payers might be shifting new IRA obligations onto manufacturers. This podcast is provided as a service of Latham & Watkins LLP. Listening to this podcast does not create an attorney client relationship between you and Latham & Watkins LLP, and you should not send confidential information to Latham & Watkins LLP. While we make every effort to assure that the content of this podcast is accurate, comprehensive, and current, we do not warrant or guarantee any of those things and you may not rely on this podcast as a substitute for legal research and/or consulting a qualified attorney. Listening to this podcast is not a substitute for engaging a lawyer to advise on your individual needs. Should you require legal advice on the issues covered in this podcast, please consult a qualified attorney. Under New York's Code of Professional Responsibility, portions of this communication contain attorney advertising. Prior results do not guarantee a similar outcome. Results depend upon a variety of factors unique to each representation. Please direct all inquiries regarding the conduct of Latham and Watkins attorneys under New York's Disciplinary Rules to Latham & Watkins LLP, 1271 Avenue of the Americas, New York, NY 10020, Phone: 1.212.906.1200

Legal News for Mon 8/12 - SCOTUS Ruling Shakes Health Agencies Enforcement Ability, Ambush (?) of El Mayo, and Another Block on Biden's Student Loan Relief

Play Episode Listen Later Aug 12, 2024 5:29

This Day in Legal History: Swiss Banks Settle with Holocaust SurvivorsOn August 12, 1998, a landmark settlement was reached when Swiss banks agreed to pay $1.25 billion to Holocaust survivors and their heirs. The settlement resolved lawsuits that accused the banks of withholding millions of dollars deposited by Holocaust victims before and during World War II. For decades, these accounts had been frozen, and the banks had been criticized for their lack of transparency and for making it difficult for survivors and their families to access the funds. The lawsuits brought to light the complex role that Swiss financial institutions played during the war, often prioritizing financial gain over moral responsibility. This settlement was seen as a significant acknowledgment of the wrongs committed and a step toward justice for the victims. The agreement also marked a broader recognition of the need to address the financial injustices faced by Holocaust survivors, setting a precedent for other restitution efforts globally. The $1.25 billion fund was distributed to survivors, heirs, and various Jewish organizations, symbolizing a long-overdue attempt to rectify the banks' wartime conduct. The settlement highlighted the intersection of financial institutions, moral responsibility, and historical accountability in the aftermath of one of history's greatest tragedies.The recent Supreme Court ruling in SEC v. Jarkesy has sent shockwaves through federal health agencies, significantly impacting their ability to impose civil penalties. The decision, which requires a jury trial for civil penalties in SEC cases, is expected to influence how agencies like the Department of Health and Human Services (HHS), the Centers for Medicare & Medicaid Services (CMS), and the Food and Drug Administration (FDA) conduct enforcement actions. Legal experts suggest that this ruling could lead to increased legal challenges from healthcare entities, such as hospitals and drugmakers, against penalties imposed by these agencies. The ruling has raised questions about the constitutionality of administrative procedures, particularly those handled by administrative law judges, and may force agencies to reassess their enforcement strategies. The decision could also slow down current enforcement actions while agencies evaluate their legal standing. This ruling is likely to embolden those facing civil penalties to challenge the HHS and its agencies in court, especially in areas like Medicare, tobacco regulation, and the 340B Drug Pricing Program.By way of very brief background, in SEC v. Jarkasy, the Fifth Circuit held that the SEC's administrative enforcement of fraud claims without jury trials violated the Seventh Amendment, as such claims involve traditional common law matters warranting a jury. The court also ruled that the Dodd-Frank Act's broad delegation of authority to the SEC to choose between administrative proceedings and federal court without clear guidelines violated the nondelegation doctrine. Additionally, the protections against removal for administrative law judges (ALJs) were found to infringe on the President's duty under Article II. The Supreme Court later upheld the Seventh Amendment violation but did not address the other issues.Health Agency Approach on Civil Penalties Shaken by High CourtIsmael "El Mayo" Zambada, a prominent Mexican drug lord and co-founder of the Sinaloa Cartel, claimed he was deceived and forcibly taken to the United States last month. In a statement released by his lawyer, Zambada alleged that he was lured into a meeting by Joaquin Guzman Lopez, the son of his former partner Joaquin "El Chapo" Guzman, and state officials in Sinaloa. He recounted being ambushed, restrained, and flown to the U.S. under duress. Contrary to Zambada's account, Guzman Lopez's lawyer and U.S. authorities assert that Guzman Lopez surrendered voluntarily after negotiations. During the incident, Zambada claims that one of the officials involved, Hector Cuen, was killed, and his bodyguard has since disappeared. Both Zambada and Guzman Lopez have pleaded not guilty to drug-trafficking charges in the U.S.'El Mayo' says he was ambushed in new account of US arrest | ReutersA federal appeals court has extended an order blocking President Joe Biden's administration from implementing its student debt relief plan, which aimed to lower monthly payments and accelerate loan forgiveness for millions of borrowers. The 8th U.S. Circuit Court of Appeals, responding to an appeal from seven Republican-led states, granted an injunction that halts further implementation of the Saving on a Valuable Education (SAVE) Plan. This ruling follows a previous order that temporarily blocked parts of the plan. The court's decision means that while loans already forgiven won't be reversed, future implementations are on hold. The Biden administration criticized the ruling, arguing it would increase costs for borrowers, while the Republican-led states contend that the administration exceeded its legal authority with the plan. The SAVE Plan, which had partially taken effect, was projected to benefit over 20 million borrowers but now faces legal hurdles that may delay or alter its future. This development follows earlier challenges to Biden's broader $430 billion debt cancellation initiative, which was blocked by the U.S. Supreme Court in 2023.Federal court extends block on Biden's student debt relief plan | Reuters This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.minimumcomp.com/subscribe

Legal News for Fri 6/28 - 5th Circuit Conservative Push Continues, Home Health Industry Renews Lawsuit Against Medicare Cuts and NFL Antitrust Verdict

Play Episode Listen Later Jun 28, 2024 18:01

This Day in Legal History: Regents of the University of California v. BakkeOn June 28, 1978, the US Supreme Court delivered a landmark decision in the case of Regents of the University of California v. Bakke, shaping the future of affirmative action in university admissions. The case centered around Allan Bakke, a white applicant who was twice denied admission to the University of California, Davis Medical School, despite having higher test scores than some minority candidates who were admitted under a special admissions program. Bakke argued that he was a victim of racial discrimination.The Court's ruling was complex, resulting in a split opinion. By a narrow 5-4 margin, the Supreme Court held that the university's use of rigid racial quotas, specifically reserving 16 out of 100 seats for minority students, violated the Equal Protection Clause of the Fourteenth Amendment and the Civil Rights Act of 1964. This decision invalidated the quota system used by the university.However, the Court also ruled, in a separate 5-4 vote, that race could be considered as one of many factors in the admissions process. This part of the decision, delivered by Justice Lewis Powell, emphasized that while quotas were unconstitutional, affirmative action programs aimed at increasing diversity and providing opportunities for historically disadvantaged groups could be constitutionally permissible.The Bakke decision was a pivotal moment in the ongoing debate over affirmative action, setting a precedent that continues to influence educational policies and the broader discourse on racial equality in the United States. The case highlighted the delicate balance between prohibiting racial discrimination and promoting diversity and inclusion in higher education.Despite repeated reversals from the Supreme Court, the US Court of Appeals for the Fifth Circuit has continued to push conservative legal boundaries. This term, the Supreme Court reversed or vacated six out of nine Fifth Circuit decisions, yet still made significant rulings in favor of conservative positions, including limiting the Securities and Exchange Commission's (SEC) enforcement power and rejecting a federal bump stock ban. Observers note that while the Supreme Court often overturned Fifth Circuit rulings, it also aligned with the circuit's conservative ideology in key cases.A notable example was the Supreme Court's decision that people subject to civil penalties for alleged securities fraud have a constitutional right to a jury trial, significantly impacting the SEC's adjudication process. Another major case saw the Supreme Court upholding the Fifth Circuit's rejection of the bump stock ban, a regulation initially issued by the Trump administration. The Fifth Circuit also won a case involving incomplete deportation hearing notices, which, though technical, reflected the court's influence. However, the Supreme Court criticized the Fifth Circuit for overreaching, particularly on issues like the abortion pill mifepristone and social media censorship, emphasizing the importance of standing.The Fifth Circuit's decisions are often driven by judges appointed by former President Donald Trump, whose influence reshaped the court. Legal experts suggest that despite some setbacks, the Fifth Circuit's conservative rulings continue to shape national policies, revealing a complex interplay between the circuit and the Supreme Court.Conservatives Gain Despite Fifth Circuit Setbacks at High CourtThe home health industry is preparing to refile its lawsuit against Medicare payment cuts after a recent unfavorable court ruling. William A. Dombi, president of the National Association for Home Care & Hospice (NAHC), stated that the organization will first complete the necessary administrative appeals before returning to court. This legal battle could significantly impact Medicare home health providers and beneficiaries.The US District Court for the District of Columbia dismissed NAHC's initial lawsuit because it was filed before exhausting all administrative remedies. Instead of appealing, NAHC will follow the court's directive and refile the case. Meanwhile, industry groups are lobbying Congress to pass legislation to block a proposed 1.7% cut to home health payments in 2025.The Centers for Medicare & Medicaid Services (CMS) proposed a 2.5% payment increase but also a 3.6% cut due to a “permanent behavior adjustment” and a 0.6% cut for outlier payments. This is the third consecutive year of proposed cuts, which, according to Joanne Cunningham, CEO of the Partnership for Quality Home Healthcare, make it difficult for providers to meet the growing care demands of an aging population. High labor costs and workforce shortages exacerbate these challenges, and Katie Smith Sloan of LeadingAge noted that the cuts make it harder to recruit nurses.Senators Debbie Stabenow and Susan Collins, along with Representatives Terri Sewell and Adrian Smith, have introduced legislation to block the CMS proposal and restrict its authority over payment adjustments based on provider behavior. Dombi emphasized ongoing efforts with lawmakers, indicating that CMS is unlikely to change its stance.The Medicare Payment Advisory Commission (MedPAC) has consistently recommended reductions in home health payments, citing that current payments are significantly higher than costs. Their latest report projects a profit margin of 18% for 2024, arguing that excess payments diminish the value of home health care. However, Dombi countered that MedPAC's estimates don't account for lower payments from private Medicare Advantage plans, which now cover a majority of Medicare beneficiaries.Home Health Agencies to Renew Suit Over Medicare Payment RatesA California federal jury has ordered the National Football League (NFL) to pay over $4.7 billion in damages for overcharging subscribers of its "Sunday Ticket" telecasts. The jury found that the NFL conspired with member teams to inflate the price of "Sunday Ticket" for millions of residential and commercial subscribers. This decision followed more than a decade of litigation. The plaintiffs, who were DirecTV subscribers, argued that the NFL's agreements with broadcast partners allowed DirecTV to charge higher prices by monopolizing distribution. A judge may triple the damages under U.S. antitrust law, potentially bringing the total to over $14 billion. The NFL plans to contest the verdict.NFL hit with $4.7 billion verdict in 'Sunday Ticket' antitrust trial | ReutersThis week's closing theme is by Ludwig van Beethoven, once again, and still a composer of some note.As we close out this week, we turn to the life and music of Ludwig van Beethoven, one of classical music's most iconic figures. On June 28, 1802, Beethoven penned a poignant letter to his friend Franz Wegeler, revealing his deep struggles with his worsening deafness. Despite the profound personal challenge this posed, Beethoven's determination to overcome his condition fueled some of his most extraordinary compositions.In light of this story, our closing theme is Beethoven's "Symphony No. 3 in E-flat major, Op. 55," commonly known as the "Eroica Symphony." This symphony, composed between 1803 and 1804, epitomizes Beethoven's resilience and innovation. Originally dedicated to Napoleon Bonaparte, whom Beethoven admired for his democratic ideals, the dedication was famously retracted when Napoleon declared himself emperor. The "Eroica" is renowned for its emotional depth and groundbreaking structure, marking a significant shift from classical to romantic symphonic form.Beethoven's ability to compose such a powerful and transformative piece while grappling with the despair of impending deafness is a testament to his genius and perseverance. The "Eroica Symphony" not only reflects Beethoven's personal triumphs but also serves as an enduring symbol of human resilience in the face of adversity.As you listen to the stirring movements of this symphony, remember the indomitable spirit of Beethoven. Let his story and music inspire you as we conclude this week, reminding us all of the power of determination and the beauty that can emerge from our greatest challenges. Thank you for joining us, and we look forward to sharing more with you next week.Once again and without further ado, Ludwig van Beethoven's Symphony No. 3 in E-flat major, Op. 55, the “Eroica Symphony” – enjoy! This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.minimumcomp.com/subscribe

Legal News for Mon 5/20 - Trump Testimony in Trial, CO Groundbreaking AI Law, SCOTUS Ruling on CFPB Funding, States' Plans to Build Solar Workforce and New Fed Reqs for Nursing Homes

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Play Episode Listen Later May 20, 2024 9:40

This Day in Legal History: Free Exercise Clause Applies to StatesOn this day, May 20, in 1940, the United States Supreme Court made a landmark decision in the case of Cantwell v. Connecticut, significantly shaping the landscape of religious freedom in America. The Court held that the Free Exercise Clause of the First Amendment, which guarantees individuals the right to practice their religion freely, applied to state governments. This decision was pivotal as it extended the protections of the Bill of Rights to state actions, not just federal, through the incorporation doctrine.The incorporation doctrine is a constitutional principle that ensures the fundamental rights and freedoms outlined in the Bill of Rights are protected against infringement by state governments. This doctrine relies on the Due Process Clause of the Fourteenth Amendment, which has been interpreted to incorporate most of the protections guaranteed in the Bill of Rights. The Cantwell case was a critical moment in the application of this doctrine, marking the first time the Supreme Court applied the Free Exercise Clause to the states.In Cantwell v. Connecticut, the case involved Jehovah's Witnesses who were arrested for soliciting without a permit and for inciting a breach of the peace. The Supreme Court ruled in favor of the Cantwells, stating that their arrests violated their First Amendment rights. This decision underscored the importance of protecting religious expression from state interference and set a precedent for future cases involving the incorporation of other Bill of Rights protections.This ruling reinforced the principle that religious freedom is a fundamental right that must be respected by all levels of government, ensuring that individuals could practice their faith without undue state interference. It paved the way for broader interpretations of the First Amendment and fortified the legal framework that guards against religious discrimination and promotes religious liberty in the United States.Donald Trump, currently on trial in New York for falsifying business records, may testify in his defense this week, although his decision remains uncertain. While Trump initially indicated he would testify, his lawyer Todd Blanche has since expressed uncertainty. Trump faces 34 counts related to hush money payments to Stormy Daniels, aimed at silencing her allegations of an affair before the 2016 election, which Trump denies. Outside the courtroom, Trump has labeled the trial a politically motivated effort to undermine his 2024 presidential campaign. Inside, he has listened to testimony, including lurid details from Daniels and accounts of efforts to suppress negative stories. Prosecutors are expected to conclude their case after testimony from Michael Cohen, Trump's former fixer who made the payment to Daniels.Trump's legal team will soon present their defense, potentially calling witnesses, including Trump himself. If Trump chooses to testify, he could challenge the allegations directly but would also face rigorous cross-examination, posing risks of perjury and damaging his credibility. The outcome of this trial, one of four criminal cases Trump faces, could impact his political future.Trump has the chance to testify at hush money trial - if he so chooses | ReutersColorado is set to become the first U.S. state to enact a comprehensive law regulating the use of artificial intelligence (AI) in employment and other critical areas with Senate Bill 24-205 (SB205). Passed on May 8 and awaiting Governor Jared Polis' signature, the law aims to prevent algorithmic discrimination and will take effect in 2026. It targets high-risk AI systems influencing decisions in employment, education, finance, government services, healthcare, housing, insurance, and legal services.SB205 imposes significant compliance obligations on both developers and users of high-risk AI systems. Developers must provide detailed information about their AI systems, publish risk management strategies, and disclose known discrimination risks to the attorney general. Deployers are required to implement risk management policies, conduct annual impact assessments, and notify consumers about the use of AI systems in decision-making.The law also mandates that businesses inform consumers about the purpose and nature of AI systems, their influence on decisions, and the right to opt out of profiling. The Colorado attorney general will enforce the law, treating violations as unfair and deceptive trade practices, though there is no private right of action. Businesses can defend themselves by showing they discovered and corrected violations through feedback or internal reviews.This groundbreaking legislation is expected to influence broader AI regulation across the U.S., as other states consider similar measures, prompting employers nationwide to prepare for stricter AI compliance requirements.Colorado Passes Groundbreaking AI Discrimination Law Impacting EmployersThe U.S. Supreme Court upheld the Consumer Financial Protection Bureau's (CFPB) funding mechanism, which allows it to draw funds from the Federal Reserve rather than through annual congressional appropriations. This 7-2 decision, issued on May 16, has broader implications for other financial regulators such as the Federal Reserve, Federal Deposit Insurance Corp. (FDIC), and the Office of the Comptroller of the Currency (OCC), which also rely on independent funding mechanisms. Justice Elena Kagan, in a concurring opinion joined by Justices Sonia Sotomayor, Amy Coney Barrett, and Brett Kavanaugh, emphasized that Congress has historically used various funding mechanisms for federal agencies, underscoring the constitutionality of such arrangements. This decision signals to potential litigants that challenges against the funding of financial regulators are unlikely to succeed.The ruling reassures that the established funding methods for these agencies, which include assessing fees on the banks they supervise, are constitutionally sound. The decision also highlighted that the independent funding of U.S. regulatory agencies has long been accepted due to its prevalence and practical necessity.Dissenting Justices Samuel Alito and Neil Gorsuch, while disagreeing with the majority on the CFPB, did not find the funding methods of other regulators constitutionally problematic. They pointed out that the Federal Reserve, FDIC, and OCC operate on specific charges for services, contrasting with the CFPB's unique funding ability.Legal experts see this ruling as a robust defense of the current financial regulatory framework, suggesting that any future claims against the funding structures of these agencies will likely face significant hurdles. The case referenced is CFPB v. Community Financial Services Association of America, U.S., No. 22-448.Banking Regulators See Relief From Funding Fights in CFPB RulingStates poised to receive portions of $7 billion for bringing solar power to low-income communities face a significant skilled labor shortage in the construction industry. The Environmental Protection Agency (EPA) has selected 60 applicants, including many state energy departments, to implement the Solar for All program, aimed at providing residential solar to disadvantaged populations as part of the Greenhouse Gas Reduction Fund.The program faces a shortage of 500,000 skilled construction workers, exacerbated by early retirements and recruitment challenges, according to Ben Brubeck of the Associated Builders and Contractors. The Department of Energy's 2023 US Energy and Employment Report noted that 97% of construction employers find it difficult to hire qualified solar workers.The Solar for All funding encourages project labor agreements, which may deter non-union contractors. Currently, only about 11% of solar energy workers are unionized. This shortage raises concerns about maintaining high-quality and safe infrastructure.Labor union representatives argue that the issue is more about wages than worker availability. Higher wages, as mandated by the program, might attract more skilled workers. However, the absence of solar-specific apprenticeship programs, unlike those in other construction sectors, contributes to the labor gap.States like Michigan, Colorado, Washington, and New York are planning to address these workforce challenges during their planning periods. Michigan is considering partnerships with community colleges and labor organizations to meet the expected demand surge. Colorado aims to balance labor distribution between rural and urban areas, while Washington plans to require an apprentice for each solar installation project. New York will leverage federal funding to enhance its existing clean energy jobs and workforce development programs. The EPA emphasizes that workforce development is crucial for the success of Solar for All, with many applications proposing partnerships to build a robust clean energy workforce.States Set for Solar Cash Infusion Aim to Build Worker PipelineNew federal staffing requirements for nursing homes, introduced by the Centers for Medicare & Medicaid Services (CMS) in April, aim to enhance care quality but face significant hurdles due to waivers and exemptions. These regulations, set to take full effect in 2026, mandate specific staffing levels for registered nurses (RNs) and nurse aides. However, federal laws and the Social Security Act allow states and the Health and Human Services (HHS) secretary to grant waivers, potentially delaying compliance for many facilities.Thousands of nursing homes may qualify for exemptions from these staffing requirements, which worries advocates like Sam Brooks from the Consumer Voice for Quality Long-Term Care. These exemptions could disproportionately benefit poorly performing homes, undermining the rule's intent. Enforcement is further complicated by a shortage of state nursing home inspectors, affecting timely compliance verification.The rule stipulates that facilities must provide 3.48 hours of care per resident per day (HPRD), with specific hours allocated to RNs and nurse aides. Significant staffing gaps exist, with an estimated need for 12,000 RNs and 77,000 nurse aides to meet the new standards. Facilities in nonrural areas have three years to comply, while rural ones have five.Exemptions are not guaranteed; facilities must document efforts to hire staff and meet transparency requirements. Critics argue the exemption process is cumbersome and may lead to facility downsizing or closures, limiting seniors' access to care. CMS aims to encourage compliance through these transparency and documentation mandates, but industry representatives are concerned about the feasibility and impact of these rules. The ongoing labor shortage in the nursing home sector and the high cost of compliance, estimated at $43 billion over 10 years, present additional challenges to the successful implementation of these staffing requirements.Nursing Home Watchers Wary of Staffing Rule Waivers, Exemptions Get full access to Minimum Competence - Daily Legal News Podcast at www.minimumcomp.com/subscribe

A Fond Farewell: Musings on the End of the Medicare Advantage Hospice Carve-In Demonstration

ceo centers musings demonstrations hospice carve medicare advantage fond farewell husch blackwell medicare medicaid services cms

Play Episode Listen Later Mar 13, 2024 35:11

It came as a surprise to our team when we learned that the Centers for Medicare & Medicaid Services (CMS) was ending the hospice component of Value-Based Insurance Design (VBID) on December 31, 2024. Upon learning this, Husch Blackwell's Meg Pekarske contacted Chris Comeaux, the president and CEO of Teleios Collaborative Network, to see if he wanted to share his thoughts on this unexpected turn of events and what may be on the horizon. This is a forward-looking conversation where we explore how the lessons learned can galvanize new advocacy on the best ways to care for patients with advanced illnesses.

Medicare Advantage: An origin story

Inside Angle

Play Episode Listen Later Nov 16, 2023 36:05

Medicare Advantage has been around for decades, but how much do you know about this historic program? Learn directly from one of the driving forces behind Medicare Advantage, Tom Scully, former administrator of the Centers for Medicare & Medicaid Services (CMS). He dives into the history of the program, how health plans have evolved over time and how value-based care models will shape the future of health care.

origin stories centers medicare advantage medicare medicaid services cms tom scully

A Very “Special” Episode: Amid Controversy, CMS Launches the Hospice Special Focus Program

controversy amid centers launches hospice cms special focus husch blackwell medicare medicaid services cms

Play Episode Listen Later Nov 6, 2023 20:46

Centers for Medicare & Medicaid Services (CMS) devised a “Special Focus Program” to identify poor performing hospices and help them improve through more frequent surveys and technical assistance. CMS would also impose enforcement remedies and fines to further incentivize improvement. How to identify poor performing hospices, however, has sparked concern among the hospice community. In this episode, Husch Blackwell's Meg Pekarske and Bryan Nowicki discuss the Hospice Special Focus Program and what hospices can expect from that program as it rolls out in 2024.

Reframing Nursing Home Reform as a Housing Issue

Elevate Eldercare

Play Episode Listen Later Oct 25, 2023 42:05

In both the public and policymaker imagination, nursing home reform is strictly a health care issue, the domain of state health departments and the federal Centers for Medicare & Medicaid Services (CMS). But the prevalence of subpar nursing homes — and lack of empowering, person-directed alternatives to an aging long-term care infrastructure — is just as much the result of housing policy as health care regulations. Well-known LTC researcher David Grabowski of Harvard University returns to “Elevate Eldercare” to discuss his increasing focus on the Department of Housing and Urban Development (HUD) as a key lever for eldercare transformation. By tweaking a few of the incentives that HUD currently offers nursing home operators, and implementing strict oversight to ensure the proper use of any additional funding, Green House homes and other alternatives could rapidly enter the marketplace. Grabowski also walks through some of the progress made by the Moving Forward Coalition, a broad-based group seeking to implement the recommendations made in a sweeping 2022 report on the state of U.S. nursing home care from the National Academies of Sciences, Engineering, and Medicine (NASEM). Learn more about the Moving Forward Coalition, including the new action plans: https://movingforwardcoalition.org/taking-action/#ActionPlans Register for Change the Incentives, Change the System, a December 7 webinar on how small Medicaid policy changes can ignite innovation, here: https://thegreenhouseproject.org/projects/change-the-incentives-change-the-system-a-green-house-medicaid-case-study

change system engineering housing harvard university reform sciences centers reframing incentives medicaid nursing homes hud ltc national academies grabowski urban development hud medicare medicaid services cms

New Podcast -- Discussion with Rita Redberg and Angela Lu regarding Their Study on Conflict of Interest

Sensible Medicine

Play Episode Listen Later Oct 5, 2023 35:12

Angela Lu is training to be a physician. She's interested in public policy. As a third year medical student, she teamed up with established leaders to ask a unique question regarding public disclosure of financial relationships. When the Centers for Medicare & Medicaid Services (CMS) issues National Coverage Determinations (NCDs) for services or products, they mean business. Such decisions have huge implications. You cannot go against them. Think #HighConsequences.CMS studies the evidence and publishes a proposed decision. It then allows public comments. People care. The idea behind their study, which made it into the Journal of the American Medical Association, was to study how many commenters disclosed their financial conflicts. Dr. Lu went through more than 680 comments submitted on 4 NCDs—all of which were high cost invasive procedures. I won't spoil the conversation, but they found a very high percentages of comments asking to expand indications for these procedures and very very low percentages of people who disclosed their relevant relationships. This study was made possible by the Open Payments database. One important note: disclosure of relationships was voluntary. Enjoy the conversation. Thanks for listening. JMM This is a public episode. If you'd like to discuss this with other subscribers or get access to bonus episodes, visit www.sensible-med.com/subscribe

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Thurs 10/5 - 9th Circuit reviewing Meta's “Citizenship Bias,” Trump-era CMS rule struck down, SBF's Trial Rolls on and Trump's Judge Frustration

Healthy Outcomes: A Baker Tilly Podcast

Play Episode Listen Later Oct 5, 2023 8:48

On this day in legal history, October 5, 1941, Supreme Court Justice Louis Brandeis died at the age of 84. Louis Brandeis was born on November 13, 1856, in Louisville, Kentucky. He graduated from Harvard Law School at the age of 20 with the highest grade point average in the school's history. In 1890, he gained recognition for developing the "right to privacy" concept through an article in the Harvard Law Review. Brandeis was a prominent figure in the antitrust movement and was known for his resistance to monopolies, particularly in the New England railroad sector. He also advised Woodrow Wilson and was critical of large banks and powerful corporations in his writings.Brandeis became active in the Zionist movement, viewing it as a solution to antisemitism in Europe and Russia. He was often referred to as the "People's Lawyer" and took cases without pay to focus on broader issues. He set a new precedent in evidence presentation with the "Brandeis brief," which utilized expert testimony from various professions. In 1916, President Woodrow Wilson nominated him to the U.S. Supreme Court, making him the first Jewish member. His nomination was met with significant opposition but was eventually confirmed by the Senate.During his tenure on the Supreme Court from 1916 to 1939, Brandeis became one of the most influential justices in history. He was known for his strong defenses of freedom of speech and the right to privacy. However, he has been criticized for not addressing issues related to African-Americans and for supporting racial segregation in some cases. Brandeis retired from the Supreme Court on February 13, 1939, and passed away on October 5, 1941, in Washington, D.C.The U.S. Court of Appeals for the Ninth Circuit is set to hear a case concerning Meta Platforms Inc., the parent company of Facebook, and its alleged preference for hiring workers on H-1B visas. The case, brought by appellant Purushothaman Rajaram, questions whether U.S. citizens are a protected class under Section 1981 of the 1866 Civil Rights Act. A federal district court previously dismissed the case, stating that the act does not cover "reverse discrimination" claims. Rajaram's lawyers argue that Section 1981 should be broadly interpreted to include U.S. citizens, while Meta contends that the law has traditionally been applied narrowly to race or alien status.The case also brings into focus Meta's hiring practices. The company was one of the top H-1B employers in fiscal year 2022, with over 1,500 approved petitions for new workers. Rajaram, a naturalized U.S. citizen, claims that Meta's hiring policies favor workers on H-1B visas over equally or more qualified U.S. citizens. If Rajaram wins, it could discourage companies from prioritizing H-1B workers over U.S. citizens.The Department of Justice and the Department of Labor have previously scrutinized Meta's H-1B hiring practices. The company settled those claims by paying over $14 million in civil penalties without admitting any wrongdoing. Rajaram's lawsuit aims to address citizenship discrimination in hiring more broadly, not just positions earmarked for visa workers.Experts note that the structure of the H-1B program itself may contribute to competition between visa holders and U.S. workers. Companies have little incentive to pay H-1B workers more than the prevailing wage, leading them to file as many petitions as possible for minimally qualified candidates. The case began with oral arguments yesterday. Meta's H-1B Hiring Spurs Ninth Circuit Look at Citizenship BiasA federal judge has ordered the Centers for Medicare & Medicaid Services (CMS) to withdraw a Trump-era rule concerning copay assistance programs. The rule had been challenged by patient advocacy groups, including the HIV+Hepatitis Policy Institute and the Diabetes Leadership Council, who claimed it allowed health plans to increase out-of-pocket prescription drug costs. Judge John D. Bates stated that the rule conflicted with the Affordable Care Act's definition of "cost-sharing" and must be set aside.The 2020 rule had stated that pharmacy benefit managers (PBMs), who manage prescription drug benefits for insurers, were not required to count drugmaker copay assistance toward patients' out-of-pocket costs. The patient groups argued that this allowed PBMs and health plans to collect funds from both patients and drugmakers without using the money to ease the financial burden on patients.The ruling is seen as a victory for these patient advocacy groups, who filed the lawsuit in August 2022. Carl Schmid, the executive director of the HIV+Hepatitis Policy Institute, expressed satisfaction with the court's decision and called on the Biden administration to enforce it immediately.The advocacy groups are backed by pharmaceutical companies like Pfizer, Johnson & Johnson, Abbott Laboratories, Eli Lilly & Co., and Merck & Co. While these companies can offer assistance to patients in commercial plans, such programs are prohibited in government-funded health insurance due to the Anti-Kickback Statute.The Department of Health and Human Services (HHS) had previously argued that manufacturer coupons could add long-term costs to the healthcare system, outweighing the short-term benefits. Both the Department of Justice, representing CMS and HHS, and a CMS spokesperson declined to comment on the ruling. The case is titled HIV & Hepatitis Policy Inst. v. Dep't of Health & Human Servs. and was filed on September 29, 2023.Judge Strikes Down Trump-Era Medicare Copay Assistance Rule (1)The trial of Sam Bankman-Fried, founder of the collapsed FTX cryptocurrency exchange, has begun with both sides presenting differing views on the reasons behind the company's failure. Bankman-Fried is accused of using FTX customer funds to support his hedge fund, Alameda Research, as well as for personal expenditures like luxury real estate and political donations. He has pleaded not guilty to these charges. His defense lawyer, Mark Cohen, portrayed him as a "math nerd" from MIT who may have overlooked risk management but did not engage in theft.Prosecutor Thane Rehn, however, argued that Bankman-Fried took more than $10 billion from FTX customers and used the funds to build his empire through fraudulent means. Rehn stated that the defendant "doubled down" on risky investments when Alameda began losing money. The prosecution plans to call three former associates of Bankman-Fried, all of whom have pleaded guilty and agreed to cooperate, to testify against him.The defense suggested that these witnesses might retrospectively portray Bankman-Fried's decisions as deceitful, even though they had agreed with those decisions at the time. The jury for the trial includes a diverse group of individuals, including a retired investment banker, a school librarian, and a train conductor. Bankman-Fried has been in detention since August 11 for likely tampering with witnesses.The trial comes nearly a year after the collapse of FTX, which had a significant impact on financial markets and damaged Bankman-Fried's reputation. It promises to offer an inside look into the operations of a cryptocurrency exchange and the legal boundaries within which such businesses operate.Sam Bankman-Fried trial jurors hear competing explanations for FTX collapse | ReutersJudge Arthur Engoron, overseeing Donald Trump's civil fraud trial in New York, expressed frustration with Trump's legal team for what he termed as "ridiculous" and redundant questioning of a witness. The trial is centered on allegations by the New York attorney general's office that Trump inflated his net worth by billions to secure better loan and insurance terms. Engoron, who is the sole decider of the case's outcome, has already disciplined Trump's lawyers for making "frivolous" arguments.Earlier, Engoron had imposed a gag order on public comments about court staff after Trump criticized the judge's top law clerk on social media. Trump, who has been present in court, has consistently attacked both the judge and New York Attorney General Letitia James, labeling them as "corrupt" and the case as a "sham."Last week, Engoron ruled that Trump, his two adult sons, and 10 of his companies had committed fraud. He revoked the business certificates for key assets, including Trump Tower and 40 Wall Street, and said he would appoint receivers for their dissolution. Trump's lawyers have appealed this decision.The trial mainly concerns the assessment of damages, with James seeking at least $250 million in fines and various bans against Trump and his sons from conducting business in New York. The trial is expected to continue until mid-December. Trump also faces other legal challenges, including four criminal indictments and a civil damages trial scheduled for January. He has denied wrongdoing in all cases.Judge chides Donald Trump lawyer's 'ridiculous' questioning in civil fraud trial | Reuters Get full access to Minimum Competence - Daily Legal News Podcast at www.minimumcomp.com/subscribe

Final Medicare hospital inpatient prospective payment system (IPPS) and proposed outpatient prospective payment system (OPPS) changes for fiscal year 2024

Play Episode Listen Later Sep 26, 2023 36:13

On this episode of Healthy Outcomes, our host Mark Ross interviews Baker Tilly's Keith Hutcheson, Partner, and Brian Restivo, Director in Baker Tilly's acute care reimbursement practice. Together, they discuss the final rule issued by the Centers for Medicare & Medicaid Services (CMS) for the federal fiscal year (FY) 2024 related to the hospital inpatient prospective payment system (IPPS) which will become effective Oct. 1, 2023. In addition, they discuss the proposed outpatient prospective payment system (OPPS) rule which will become effective Jan. 1, 2024. Follow UsTwitter @bakertillyusFacebook @BakerTillyUSInstagram @bakertillyusPresented by Baker Tilly https://www.bakertilly.com/

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Episode 54 – Drug Pricing: Focus on Best Price — CMS Proposed Rule, Inflation Reduction Act

Play Episode Listen Later Sep 15, 2023 13:17

In a proposed rule issued earlier this summer, the Centers for Medicare & Medicaid Services (CMS) suggested expanding the scope of combining, or stacking, discounts when determining best price. Meanwhile, the Inflation Reduction Act amended the statutory best price definition to include maximum fair prices negotiated under CMS's new Medicare price negotiation authority. In this episode of Connected with Latham, partner Chris Schott and associate Danny Machado explain how CMS's proposed rule on best price stacking differs from past interpretations, and discuss possible ways CMS could implement the Inflation Reduction Act's statutory change to the best price definition. This podcast is provided as a service of Latham & Watkins LLP. Listening to this podcast does not create an attorney client relationship between you and Latham & Watkins LLP, and you should not send confidential information to Latham & Watkins LLP. While we make every effort to assure that the content of this podcast is accurate, comprehensive, and current, we do not warrant or guarantee any of those things and you may not rely on this podcast as a substitute for legal research and/or consulting a qualified attorney. Listening to this podcast is not a substitute for engaging a lawyer to advise on your individual needs. Should you require legal advice on the issues covered in this podcast, please consult a qualified attorney. Under New York's Code of Professional Responsibility, portions of this communication contain attorney advertising. Prior results do not guarantee a similar outcome. Results depend upon a variety of factors unique to each representation. Please direct all inquiries regarding the conduct of Latham and Watkins attorneys under New York's Disciplinary Rules to Latham & Watkins LLP, 1271 Avenue of the Americas, New York, NY 10020, Phone: 1.212.906.1200

Behind the Curtain: Enhanced Provider Enrollment Oversight

centers provider enhanced enrollment cms oversight behind the curtain husch blackwell medicare medicaid services cms

Play Episode Listen Later Sep 6, 2023 43:42

In the midst of consolidation and restructuring among hospices, the Centers for Medicare & Medicaid Services (CMS) is scrutinizing initial enrollments and changes in ownership and management. In this episode, Husch Blackwell's Meg Pekarske and Adam Royal discuss new and proposed changes to CMS's provider enrollment screening and why it matters to hospices.

Fri 8/25 - Biden Admin Restores Medicaid to TX Individuals, JPMorgan Wins Under Howey, RFK Loses to YouTube, Starbucks Vs. NLRB and Big Don Gets His Mugshot

Play Episode Listen Later Aug 25, 2023 9:29

On this day in history, August 25, 1921, the U.S.–German Peace Treaty was signed in Berlin, marking a significant moment in the aftermath of World War I. The treaty was necessitated by the U.S. Senate's refusal to ratify the multilateral peace treaty signed in Versailles, leading to a separate peace agreement with Germany. The U.S. had declared war on Germany on April 6, 1917, and was part of the Allied Powers that defeated the German Empire. The end of the war saw the overthrow of the German monarchy and the establishment of a republic. Spoiler alert for those that haven't read the next chapter in the metaphorical history book yet, that would not go well.The U.S. Senate's objections to the Versailles Treaty were largely due to its provisions regarding the League of Nations. As a result, the U.S. and Germany began negotiations for a bilateral peace treaty, culminating in the signing of the treaty on August 25, 1921. The treaty became effective on November 11, 1921, after ratifications were exchanged in Berlin. It laid the foundations for American-German cooperation outside the strict supervision of the League of Nations, partially assisting the Weimar Republic in easing the burden of war reparations. Diplomatic relations were reestablished, and a supplementary treaty was signed in 1922 to decide the amount of reparations to be paid by Germany to the U.S. The signing of the treaty also led to the retirement of the Morgan silver dollar in favor of the new Peace dollar design, symbolizing a new era of peace and cooperation–in aspirations if not in reality. Treaty between the United States and Germany restoring friendly relations, signed at Berlin August 25, 1921The Biden administration is collaborating with Texas to restore Medicaid coverage to approximately 90,000 individuals who had lost it erroneously, according to senior officials from the Centers for Medicare & Medicaid Services (CMS). The officials are working with the state's Medicaid agency to reinstate coverage back to the date when it was terminated. The restoration is expected to be completed by the end of the month. This move follows a letter from Democratic House members from Texas, urging the CMS to investigate reported problems at the Texas Medicaid agency. A whistleblower letter had alleged system failures leading to incorrect coverage terminations, affecting thousands of pregnant women and seniors. The Texas Democrats accused the state of not complying with federal Medicaid requirements and called for CMS intervention. Nearly 600,000 Texans have already lost Medicaid coverage in recent months, mostly due to procedural reasons. Legislators have warned of further "catastrophic coverage losses" as Texas sends renewal notices to more enrollees. Rep. Lloyd Doggett emphasized the need for swift federal action to prevent interruptions in care for disadvantaged families.HHS Moves to Restore Medicaid Coverage to 90,000 in Texas (1)JPMorgan Chase & Co. has won a federal appeals court ruling that a $1.8 billion leveraged loan was not a security, marking a significant victory for the banking and private equity sectors. The ruling came in a securities fraud lawsuit related to a 2014 syndicated loan deal led by JPMorgan for drug-testing company Millennium Health, which later filed for bankruptcy. Currently, loan notes are not considered securities, so a ruling against JPMorgan could have had broad implications for the regulation of the leveraged loan market. If classified as securities, loans would require additional disclosures, more financial data, and quicker settlement of trades. The decision is seen as favorable for banks and private equity firms, which frequently use leveraged loans in buyout deals. Advocates for reclassifying leveraged loans have argued that it would bring transparency to an opaque part of the financial markets. The appeals court agreed with a lower court's dismissal of the plaintiff's fraud claims, finding that the notes were not securities. The Securities and Exchange Commission declined to offer its opinion on the matter, despite heavy lobbying from the Loan Syndications and Trading Association. The trustee had claimed that JPMorgan and other banks withheld crucial information about Millennium's troubles. The appeals court found that the notes did not meet three of the four factors required to be considered a security under U.S. law.The test to determine whether a financial instrument is considered a security under U.S. law comes from the Supreme Court case of SEC v. W. J. Howey Co., 328 U.S. 293 (1946). This test is commonly referred to as the Howey Test, and it has four factors that must be considered:* Investment of Money: There must be an investment of money or other tangible or definable consideration.* Common Enterprise: The investment must be in a common enterprise, meaning that the fortunes of the investor are interwoven with those of either the promoter or a third party.* Expectation of Profits: There must be an expectation of profits from the investment. This could include capital appreciation resulting from the development of the initial investment or a participation in earnings.* Efforts of Others: The profits must come solely from the efforts of others, typically the promoter or third party, not the investor. This element emphasizes that the investor must be a passive participant in the business.Subsequent cases, such as United Housing Foundation, Inc. v. Forman, 421 U.S. 837 (1975), have further clarified the Howey Test, specifically focusing on the economic realities of the scheme and noting that the form should be disregarded for the substance. Moreover, other cases such as Reves v. Ernst & Young, 494 U.S. 56 (1990), introduced a "family resemblance test" which helps in differentiating notes that are securities from those that are not.The Howey Test remains a fundamental standard in securities law, providing a broad and flexible framework to accommodate the evolving nature of investment schemes.JPMorgan Wins Ruling That Leveraged Loans Are Not Securities (2)Robert F. Kennedy Jr. has lost a bid to force Google and YouTube to restore videos in which he questioned the safety of Covid-19 vaccines. Kennedy, who is seeking to be the Democratic Party's 2024 presidential nominee, alleged that YouTube violated his First Amendment right to political speech when it removed the videos due to its medical and vaccine misinformation policies. The U.S. District Court for the Northern District of California stated that the suit is likely to fail because Google and YouTube are not state actors subject to the free speech clause of the First Amendment. Judge Trina L. Thompson denied Kennedy's motion for a temporary restraining order that would prevent the tech companies from keeping the videos off their platform. The judge ruled that emails between government officials and Google personnel about vaccine misinformation were not enough to show that YouTube's decisions were state decisions or evidence of a conspiracy to censor speech. There was no evidence that government officials demanded that Google adopt a Covid-19 misinformation policy, nor that they communicated with Google regarding Kennedy specifically. The evidence showed that communications between government officials and Google were merely "consultation and information sharing." The case is scheduled for a hearing on November 7 regarding Kennedy's motion for a preliminary injunction and the companies' motion to dismiss.RFK Jr. Loses Bid to Force YouTube to Re-Post Anti-Vax VideosStarbucks Corp. is on the verge of defeating a National Labor Relations Board (NLRB) attempt to obtain a temporary injunction from a New York federal court. US District Judge John Sinatra ruled that the NLRB's move to block the court's discovery order in the case is "repugnant" and necessitates the dismissal of the agency's injunction petition. The NLRB has until September 1 to avoid dismissal by ceasing efforts to obstruct the discovery order. This ruling is a significant victory for Starbucks' aggressive discovery strategy in response to the NLRB's attempts to quickly obtain court orders. The NLRB has authorized its General Counsel, Jennifer Abruzzo, to sue Starbucks 10 separate times for 10(j) injunctions. The NLRB has won two cases and obtained an interim settlement in a third, while Sinatra's decision could mark the second loss for the agency. Three cases are ongoing, and one authorized petition hasn't been filed yet. Abruzzo plans to challenge Sinatra's ruling at the US Court of Appeals for the Second Circuit. Starbucks Workers United criticized the decision, while a Starbucks spokesperson said the ruling made clear that the NLRB "crossed the line." The injunction case has lasted over 400 days, mainly due to discovery disputes, with Sinatra permitting Starbucks to issue nearly 22 subpoenas for various information related to union activities.Starbucks on Verge of Beating NLRB Injunction Bid in N.Y. (1)Former U.S. President Donald Trump was booked at an Atlanta jail on more than a dozen felony charges related to his attempts to overturn his 2020 election defeat in Georgia. Though his mugshot was released, the focus of the case is on the wide-ranging criminal charges he faces. Trump spent only about 20 minutes at the jail before returning to his New Jersey golf club, maintaining that the prosecution is politically motivated. Judge Scott McAfee set a trial date of October 23 for one of Trump's 18 co-defendants, but the schedule does not yet apply to Trump or the other defendants. Trump faces 13 felony counts in the Georgia case, including racketeering, for pressuring state officials to reverse his election loss. Trump's legal team is expected to push for a later trial start date. In total, Trump faces 91 criminal counts across four cases. He has pleaded not guilty in the three other cases and denied wrongdoing. In the Georgia case, arraignments are requested to begin the week of September 5. Trump agreed to post a $200,000 bond and accepted bail conditions that would bar him from threatening witnesses or his co-defendants in the Georgia case. Republicans who control the U.S. House of Representatives announced they would investigate whether the prosecutor improperly coordinated with federal prosecutors.Trump's mug shot released after booking at Georgia jail on election charges | Reuters Get full access to Minimum Competence - Daily Legal News Podcast at www.minimumcomp.com/subscribe

covid-19 united states new york california texas donald trump google peace house spoilers germany joe biden german new jersey berlin league supreme court advocates investment republicans starbucks effort senate nations sec texans loses individuals expectation centers frank sinatra democratic party medicaid first amendment verge jp morgan appeals millennium robert f kennedy jr treaty versailles general counsel cms securities restores subsequent exchange commission diplomatic district court forman legislators mugshots ernst young biden admin abruzzo nlrb us court northern district texas democrats weimar republic democratic house second circuit howey german empire jpmorgan chase co reves on this day in history starbucks workers united allied powers national labor relations board nlrb howey test judge scott mcafee versailles treaty medicare medicaid services cms american german jennifer abruzzo trading association

Episode 52 – Drug Pricing: Could a Single Reference Price Apply Across a Therapeutic Class?

Tales From Around the Water Cooler

Play Episode Listen Later Aug 21, 2023 11:16

The policy conversation related to reimbursement rates for drugs has recently turned toward pricing for entire therapeutic classes, rather than assessing the value of an individual drug. Two recent developments emphasize a growing call for establishing a single payment rate for therapeutic classes: the Medicare Payment Advisory Commission's (MedPAC) June report to Congress, and the Centers for Medicare & Medicaid Services (CMS) final guidance for the negotiation provisions of the Inflation Reduction Act. In this episode of Connected With Latham, partner Chris Schott and associate Danny Machado discuss the emerging policy signals for assessing value across therapeutic classes, rather than for individual products. This podcast is provided as a service of Latham & Watkins LLP. Listening to this podcast does not create an attorney client relationship between you and Latham & Watkins LLP, and you should not send confidential information to Latham & Watkins LLP. While we make every effort to assure that the content of this podcast is accurate, comprehensive, and current, we do not warrant or guarantee any of those things and you may not rely on this podcast as a substitute for legal research and/or consulting a qualified attorney. Listening to this podcast is not a substitute for engaging a lawyer to advise on your individual needs. Should you require legal advice on the issues covered in this podcast, please consult a qualified attorney. Under New York's Code of Professional Responsibility, portions of this communication contain attorney advertising. Prior results do not guarantee a similar outcome. Results depend upon a variety of factors unique to each representation. Please direct all inquiries regarding the conduct of Latham and Watkins attorneys under New York's Disciplinary Rules to Latham & Watkins LLP, 1271 Avenue of the Americas, New York, NY 10020, Phone: 1.212.906.1200

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Ep. 6 - Health Insurance and Employment

Play Episode Listen Later Aug 9, 2023 38:08

Kristen Prinz welcomes Alexandra Eidenberg, president and founder of The Insurance People, an award-winning insurance agency specializing in employee benefits, individual health insurance, and Medicare. Kristen and Alexandra discuss the variety of ways that health insurance can be related to one's employment, touching upon employer plans, individual plans, Illinois coverage continuation, and COBRA. They also address what to keep in mind when your employment is coming to an end and what to look for when determining which insurance option is best for you. If you've ever had questions about health insurance, how it's tied to employment, and what to do when it's not, this is the episode for you! Stay Connected & Learn More: The Prinz Law Firm Kristen Prinz Alexandra Eidenberg Alexandra has been a licensed agent for 18 years, an agency owner for 13 years, and is locally and nationally recognized for her leadership, both as an insurance agent and a community leader. She is deeply passionate about her community and helping people. The Insurance People In 2022, The Insurance People was named the #1 US Small Group Agency by Mutual of Omaha, the #2 Illinois Agency by UnitedHealthcare, the Small Group Business Partner of the Year by Delta Dental of Illinois, and was awarded Elite Plus Status by the U.S. Centers for Medicare & Medicaid Services (CMS). The Insurance People is known and loved for its exemplary customer service. The Insurance People on Facebook The Insurance People on Instagram The Insurance People on LinkedIn

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Episode 51 – Drug Pricing: Final IRA Price Negotiation Guidance – How CMS Addressed the Part D/B Problem

Healthy Outcomes: A Baker Tilly Podcast

Play Episode Listen Later Jul 31, 2023 10:53

The Centers for Medicare & Medicaid Services (CMS) recently published its final guidance to implement the drug price negotiation provisions of the Inflation Reduction Act. While retaining the active moiety/active ingredient approach to identifying drugs subject to negotiation, CMS now will only include those products with historic or likely Part D utilization in negotiations in 2026. This is intended to avoid subjecting Part B drugs to the process sooner than the statute provides. In this episode of Connected With Latham, partner Chris Schott and associate Danny Machado of the firm's DC office explain how CMS structures its final guidance and what questions remain for drug manufacturers. This podcast is provided as a service of Latham & Watkins LLP. Listening to this podcast does not create an attorney client relationship between you and Latham & Watkins LLP, and you should not send confidential information to Latham & Watkins LLP. While we make every effort to assure that the content of this podcast is accurate, comprehensive, and current, we do not warrant or guarantee any of those things and you may not rely on this podcast as a substitute for legal research and/or consulting a qualified attorney. Listening to this podcast is not a substitute for engaging a lawyer to advise on your individual needs. Should you require legal advice on the issues covered in this podcast, please consult a qualified attorney. Under New York's Code of Professional Responsibility, portions of this communication contain attorney advertising. Prior results do not guarantee a similar outcome. Results depend upon a variety of factors unique to each representation. Please direct all inquiries regarding the conduct of Latham and Watkins attorneys under New York's Disciplinary Rules to Latham & Watkins LLP, 1271 Avenue of the Americas, New York, NY 10020, Phone: 1.212.906.1200

Proposed Medicare hospital inpatient prospective payment system (IPPS) for fiscal year 2024

Play Episode Listen Later Jun 20, 2023 30:54

On this episode of Healthy Outcomes, our host Mark Ross interviews Baker Tilly's Keith Hutcheson, Partner, and Brian Restivo, Senior Manager in Baker Tilly's acute care reimbursement practice. Together, the three of them discuss the proposed rule issued in April 2023 by the Centers for Medicare & Medicaid Services (CMS) for federal fiscal year (FY) 2024 related to the hospital inpatient prospective payment system (IPPS). Follow UsTwitter @bakertillyusFacebook @BakerTillyUSInstagram @bakertillyusPresented by Baker Tilly https://www.bakertilly.com/

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From Boardrooms to Playrooms

Her Story - Envisioning the Leadership Possibilities in Healthcare

Play Episode Listen Later May 17, 2023 17:43

Meet Our Guests: Dr. Janice Nevin, President and CEO of ChristianaCare, Chiquita Brooks-LaSure, Administrator for the Centers for Medicare & Medicaid Services (CMS), and Cathy Jacobson, President and CEO of Froedtert Health delve into the experiences and challenges faced by working mothers. Key Insights: From the struggle to achieve work-life balance and the burden of guilt and societal expectations, to the constant search for reliable childcare and the impact on career progression, working mothers navigate a complex web of responsibilities. ● Work-Family Balance. Despite challenges, working mothers display remarkable resilience and resourcefulness. Dr. Nevin emphasizes the importance of making intentional choices and prioritizing what is important to oneself in terms of career and personal life.● You Are Not Alone. Chiquita mentions how being a parent has contributed to her expertise and how talking to other parents has provided valuable insights. It is important to seek advice and support from others to not feel like one has to face challenges alone.● Support Matters. Cathay shares her experiences as a CFO, emphasizing the importance of employer understanding and support, as well as a supportive partner. Relevant Links: Listen to Dr. Janice Nevin's full episodeListen to Chiquita Brooks-LaSure's full episodeListen to Cathy Jacobson's full episode

142. Part 2: Aligning Quality Measures

director medicine md aligning centers chief medical officers cms new england journal fleisher quality measures medicare medicaid services cms clinical standards

Play Episode Listen Later Apr 17, 2023 26:29

Josh and Brian are joined by Lee Fleisher, MD, Chief Medical Officer at the Centers for Medicare & Medicaid Services (CMS) and Director of the Center for Clinical Standards and Quality. They discuss a recent publication, “Aligning Quality Measures at CMS” in the New England Journal of Medicine which Dr. Fleisher co-authored, and the art and science behind the selection of health care quality measures.

Representation Matters

Her Story - Envisioning the Leadership Possibilities in Healthcare

Play Episode Listen Later Apr 5, 2023 19:24

Meet Our Guest: Chiquita Brooks-LaSure is the Administrator for the Centers for Medicare & Medicaid Services (CMS), where she will oversee programs including Medicare, Medicaid, the Children's Health Insurance Program (CHIP), and the HealthCare.gov health insurance marketplace. She has decades of experience in the federal government and played a key role in guiding the Affordable Care Act (ACA) through passage and implementation. She led the agency's implementation of ACA coverage and insurance reform policy provisions and assisted House leaders in passing several healthcare laws. Brooks-LaSure began her career as a program examiner and lead Medicaid analyst for the Office of Management and Budget.Key Insights: Chiquita Brooks-LaSure discusses challenges of work-life balance, especially for women and mothers, and her efforts to promote health equity at CMS. ● Support is Necessary. As the first Black female administrator of the Centers for Medicare and Medicaid Services (CMS), Chiquita gives credit to mentorship and supportive colleagues, particularly women who helped her grow both professionally and personally.● Representation Matters. Diverse perspectives, including experiences and race, make a difference in decision-making. It is important to see women of color in powerful roles.● Health Equity. The core of health equity is making sure that everyone has the opportunity to achieve optimal health, which is something Chiquita works at every day. This episode is hosted by Ceci Connolly. She is a member of the Advisory Council for Her Story and President and CEO of the Alliance of Community Health Plans.Relevant Links: CMS LeadershipFollow Chaquita on Twitter

141. Aligning Quality Measures - Improving the System for Clinicians and Patients

director system patients md improving aligning medicare centers mph deputy director cms clinicians chief transformation officer quality measures medicare medicaid services cms clinical standards

Play Episode Listen Later Apr 3, 2023 32:00

Josh and Brian are joined by Doug Jacobs, MD, MPH, Chief Transformation Officer in the Center for Medicare at the Centers for Medicare & Medicaid Services (CMS), and Michelle Schreiber, Deputy Director for the Centers for Clinical Standards and Quality at CMS, and Director of the Quality Measurement & Value-Based Incentives Group at CMS. In the first part of this quality-focused series, they discuss the work they are doing to align quality measures across CMS and improve the system to benefit both clinicians and patients.

CMS's Proposed Government Overpayment Rule Sure to Make You Sleep Less

Krieg DeVault Podcast Series

Play Episode Listen Later Feb 8, 2023 18:00

Krieg DeVault Healthcare Regulatory Lawyer, Brandon W. Shirley breaks down his recent alert on the proposed overpayment rule issued by the Centers for Medicare & Medicaid Services (CMS).

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#177 Medicaid Madness

The Better for America Podcast

Play Episode Listen Later Dec 7, 2022 5:18

In this Better for America Newsline Exclusive, AMAC CEO Rebecca Weber unfolds “Biden Turning Medicare into Welfare For All” explaining how the Biden administration's Centers for Medicare & Medicaid Services (CMS) is proposing a new regulation that would make things much worse.

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EP387: Medicare Advantage Trends and How Medicare Advantage Plans Will or Will Not Succeed, With Betsy Seals, CEO and Cofounder of Rebellis Group

Relentless Health Value

Play Episode Listen Later Dec 1, 2022 34:50

Here's a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean success in all of its financial glory—because they have experience and the scale and also the specialized departments who keep track of all kinds of intricacies that are rate critical to MA success. Specifically, things Betsy Seals talks about as critical success factors, for example, are having relationships with brokers and health systems and other provider organizations. She also makes it clear how much local market knowledge is necessary. A benefit design working great in one local market might be a medical trend disaster in another area with different levels of social determinants of health (SDoH) or different disease patterns, so scaling into new areas isn't a matter of just cutting and pasting. History has shown it's easy enough to go down in a flaming ball of unanticipated medical trend and/or OIG/DOJ scrutiny. So, this is one thing that big MA carriers can get right and potentially, for sure, benefit patients in their plans. Now I say this knowing full well that there's a brouhaha afoot in which there are some who are really pro-MA and there are some who are really not. In this show with Betsy Seals today, we do not get into this (ie, Do patients in MA plans fare better than patients in traditional Medicare?). But I have a point to make, and I'm just gonna make it here. Like most “Is this better than that?” questions in healthcare, there is not one answer; and anyone running around espousing pretty much anything as a broad-stroke holy grail is pretty much full of it—and I would say that as a general statement. Whether MA is better than traditional Medicare depends on who the patient is and also which MA plan we're talking about here. So, starting on the “not a fan” side of the house, Wendell Potter has said (with evidence) that if a patient is toward the end of his or her life or acutely ill or needs to go to an NCI-designated cancer center, it could easily be deduced that traditional Medicare is going to be better. On the other hand, there seems to be evidence, including a recent JAMA article by Ravi Parikh, MD, MPP, and Ezekiel Emanuel, MD, PhD, that concludes MA produces a 22% to 26% reduction in costs compared to MSSP (Medicare Shared Savings Program) arrangements. And this is across just a general patient population of all age ranges, if I'm reading the study right. The great results that are discussed in that JAMA article are what can happen when payers and providers align to tackle SDoH and preventative stuff and are willing to go out into the community to curb potentially avoidable downstream acute events. David Carmouche, MD, by the way, on episode 343 talked at length about this. But there are variables here, and let me mention one of them: how good the Medicare Advantage plan is at risk-based contracting with physician groups. How good are they at putting patients into accountable relationships with provider organizations who are getting paid to keep patients healthy, meaning the MA plan is offering budget-based prospective payment contracts to physician groups? This is the case in that Ochsner/JAMA article example that Dr. David Carmouche was talking about. Ochsner, the health system in Louisiana, and MA plans were working together; and both assumed risk for this population. Susan Dentzer, president and CEO over at America's Physician Groups (APG), does a great job at covering a bunch of these topics on the Race to Value podcast. Another thing that will impact care quality is how good the plan leadership is at balancing patient care and shareholder demand for profit. Bottom line, it is not productive to be indiscriminately pie-eyed about pretty much anything in healthcare or throw babies out with bathwater on a regular basis. As Ge Bai, PhD, CPA, has said on this show (and others have said), there's no angels and no devils in healthcare. Everybody is some combination of both. And, in general, the only reason anybody does anything in healthcare is because it appeals to their self-interest. So, not working with some other healthcare stakeholder because we perceive them as greedy or “industry” or whatever is gonna mean that nobody is working with anybody. Just keep your eyes wide open, check the math, and in your contracts, get actual dollar amounts and not discounts. In this healthcare podcast, as mentioned a few times now, I am speaking with Betsy Seals. Betsy Seals is CEO and cofounder of Rebellis Group, a managed care consulting firm working with Medicare Advantage plans. Oh, and one acronym alert before we dive in here: SNP stands for special needs plan. A special needs plan is a Medicare Advantage coordinated care plan that is specifically designed to provide targeted care and limit enrollment to special needs individuals. So, a special needs individual could be any one of the following: An institutionalized individual A dual eligible, meaning somebody who has Medicare and Medicaid An individual with a severe or disabling chronic condition, as specified by CMS SNPs are becoming a bit of thing in the MA space this year, and Betsy talks about this trend. You can learn more at rebellisgroup.com. Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 06:16 Is Medicare Advantage still a cash cow? 06:42 Why should Medicare Advantage be the most lucrative line of business? 07:07 “If there weren't a lot of money in it, nobody would do it.” 07:29 What should you know before jumping into the Medicare Advantage market? 14:04 What issues do upstarts overlook when getting into Medicare Advantage? 17:07 What is one of the next areas that Betsy thinks CMS will crack down on? 18:24 “Look at the data.” 19:53 “I think there's a lot of lessons that you could see over the past years in the industry.” 20:52 “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” 21:02 Why don't common business models always work in healthcare businesses? 22:29 What are the new key trends coming out of the Medicare Advantage space? 26:04 Why is it important to bring in your clinicians when entering a dual market? 27:52 What's going on in the chronic conditions space? 32:14 What's necessary to the infrastructure with any kind of SNP product? 32:56 What's Betsy's forecast for the future of Medicare Advantage? You can learn more at rebellisgroup.com. @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Is Medicare Advantage still a cash cow? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why should Medicare Advantage be the most lucrative line of business? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “If there weren't a lot of money in it, nobody would do it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What should you know before jumping into the Medicare Advantage market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What issues do upstarts overlook when getting into Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What is one of the next areas that Betsy thinks CMS will crack down on? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “Look at the data.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “I think there's a lot of lessons that you could see over the past years in the industry.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why don't common business models always work in healthcare businesses? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What are the new key trends coming out of the Medicare Advantage space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why is it important to bring in your clinicians when entering a dual market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's going on in the chronic conditions space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's necessary to the infrastructure with any kind of SNP product? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's Betsy's forecast for the future of Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter

Continue to Be Curious

Her Story - Envisioning the Leadership Possibilities in Healthcare

Play Episode Listen Later Nov 30, 2022 26:14

Meet Leslie Norwalk:Leslie Norwalk serves as Strategic Counsel for Epstein Becker & Green. She sits on the boards of directors of Arvinas, ModivCare, Neurocrine Biosciences, NuVasive, and several privately held health care corporations. Leslie is also a member of APCO Worldwide's International Advisory Council. Previously, Leslie served the Bush Administration as the Acting Administrator for the Centers for Medicare & Medicaid Services (CMS). She received a bachelor's degree in economics and international relations from Wellesley College and a J.D. from George Mason University. Key Insights:Leslie Norwalk provides career insights, as well as a perspective on the implementation of Medicare Part D. Testifying for CMS. Leslie had to testify before Congress on multiple occasions. She recommends answering questions as straightforward, truthfully, and informationally as possible. Remember that your audience is broader than the person asking the question.Ignore the Bias. As a rule, Leslie tries to ignore the fact that there is gender bias. However, she still knows it exists, and always tries to be the most prepared person in the room.Sponsorship. Leslie thinks sponsorship may be as important if not more important than mentorship. To get on her first board of directors, someone sponsored Leslie and introduced her to the right people. This episode is hosted by Julie Gerberding, M.D. She is a member of the Advisory Council for Her Story and is the Chief Executive Officer for the Foundation for the National Institutes of Health. Relevant Links:Read more about Leslie NorwalkRead “Epstein Becker Green Attorneys Recognized by 2023 Best Lawyers for Excellence in the Legal Profession”

EP378: The Status of Telehealth Reimbursement and Other Telehealth Policy Updates, With Josh LaRosa, MPP

Relentless Health Value

Play Episode Listen Later Sep 8, 2022 33:16

Okay, so … telehealth for Medicare patients. Currently, there's payment parity, meaning a clinician gets paid the same amount for a Medicare patient visit regardless of whether that patient comes in the office or has a telehealth encounter. Right? Or did that end already? And if it didn't end, how much longer will payment parity continue? Also, is it the same for commercial and Medicaid patients? Congress makes rules for Medicare patients, but is it Congress that makes the rules for commercial and/or Medicaid telehealth reimbursement rates? Or how do those reimbursement decisions get made? What about the doing telehealth across state lines thing … the idea that if I'm a doc in New York, I can take a telehealth appointment with a patient in Arizona even though I am technically not licensed in Arizona? And who's in charge of that? Yeah, I went into today's conversation with Josh LaRosa, VP at Wynne Health Group, with a lot of questions. As you may suspect, this program is about telehealth. But just to level set on what we're not talking about, this interview does not dissect the “should we use the telehealth or should we not” question; and it does not get into best practices or equity concerns. For that info, listen to the show with Christian Milaster (EP320) or Liliana Petrova (EP357) or Ali Ucar (EP362) or Ian Tong, MD (EP347). Also, we are not talking about the politics, per se, of who's for telehealth and who's against it. We also aren't drilling too far into the telehealth fraud cases that are coming to light right now, but of course we cannot resist talking about them a little bit. So, let me tell you what Josh LaRosa and I are, in fact, talking about in this healthcare podcast. We're specifically discussing the near-term future of CMS reimbursement for telehealth and the allowed so-called “flexibilities” for telehealth. We talk about a few of the why's behind why are policy makers doing some of the stuff that they are doing. And then we chat about the when, how long some of the new flexibilities and reimbursements that were permitted originally during the pandemic will continue. We touch on the Cerebral incident (I guess maybe you'd call it) and the potential DEA or legislative actions that may result from that as well. An interesting point that we dig into for a couple minutes is this one: Do not forget that the whole telehealth reimbursement debate (do I wanna call it?)—Should we cover it? Should we not cover it? And for how much?—this whole debate is part of a bigger debate. A much bigger debate, actually: the fee-for-service vs the not-fee-for-service debate. That's the larger context of all of this, and I think it's often overlooked. Nobody anywhere is limiting how often a practice who wants to use telehealth as part of some kind of risk-based or capitated thing can use telehealth. Why? Because in a capitated or bundle arrangement, from a Medicare trust fund perspective at least, telehealth visits are not equivalent to additional spend or additional volume. In a non-FFS environment, there's little chance of fraud also, really. Also, patient safety—arguably, probably—becomes much more of a practice concern. It gets a lot less rewarding to do unsafe things over telehealth when you don't get automatically paid to do them … and also paid to fix the problems that resulted from the unsafe things, which is the perverse beauty of FFS that we're all so familiar with. Acronym alert! PHE stands for public health emergency. A public health emergency is the thing the government declares, for example, during a pandemic. You can learn more at wynnehealth.com or by following on Twitter and LinkedIn. Josh LaRosa, MPP, is a vice president at Wynne Health Group, focusing primarily on regulatory affairs with a focus on the US Food & Drug Administration (FDA) and Centers for Medicare & Medicaid Services (CMS). His interests lie in delivery reform and innovations in payment and care delivery models. Josh also supports the firm's Public Option Institute, which studies the emergence of public option programs at the state level. Prior to Wynne Health Group, Josh consulted for the CMS Innovation Center, where he worked to implement, monitor, and spread learning garnered from the center's high-profile demonstration projects, most recently including the national primary care redesign effort, Comprehensive Primary Care Plus (CPC+). Josh holds a Master of Public Policy from the University of Virginia's Frank Batten School of Leadership and Public Policy. He also completed his undergraduate studies at the University of Virginia, graduating cum laude with a BA in political philosophy, policy, and law. 04:09 What is the story with telehealth policy right now? 06:08 What kind of flexibilities did HHS allow with telehealth after the pandemic? 09:46 Are we still under these pandemic flexibilities for telehealth? 12:15 Why isn't the government just making greater access to telehealth permanent? 18:24 How does telehealth lend itself to the risk of overspending when dealing with an FFS model? 21:13 Does telehealth fit into the new CMS fee schedule? 22:55 How do states factor into the future of telehealth? 24:40 What is Arizona doing specifically to improve and ensure the future of telehealth? 30:56 What's next in store for telehealth at the congressional level? You can learn more at wynnehealth.com or by following on Twitter and LinkedIn. @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the story with telehealth policy right now? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What kind of flexibilities did HHS allow with telehealth after the pandemic? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are we still under these pandemic flexibilities for telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why isn't the government just making greater access to telehealth permanent? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth How does telehealth lend itself to the risk of overspending when dealing with an FFS model? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Does telehealth fit into the new CMS fee schedule? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth How do states factor into the future of telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is Arizona doing specifically to improve and ensure the future of telehealth? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's next in store for telehealth at the congressional level? @josh_larosa of @WynneHealth discusses #telehealth on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai

EP375: Medicare Advantage Plans in the Hot Seat, With Betsy Seals, CEO and Cofounder of Rebellis Group

Relentless Health Value

Play Episode Listen Later Jul 28, 2022 32:03

Medicare Advantage (MA), otherwise known as the “money machine,” is often the most profitable parts of many payers' business lines. Medicare Advantage plans can make a lot of cash if they are good at what they do. Look at any of these large, consolidated carriers' financial statements to get the magnitude of that statement. Also, in 2022, Medicare Advantage plans have enrolled 28 million participants between them, which represents 45% of all Medicare beneficiaries. This marks a three-point improvement in penetration over 2021 and a total program enrollment growth of 9%. All of this is not a secret. So, what's happening right now is that this administration is looking carefully at Medicare Advantage plans and what they have been up to. We have had an amping up of government oversight, including regulatory actions and program audits. In this healthcare podcast, I am speaking with Betsy Seals, who is CEO and cofounder of Rebellis Group, which is a managed care consulting firm working with Medicare Advantage plans. Betsy says (and this is what we talk about in the interview) that there's three main areas that the government is currently scrutinizing: Sales and marketing. There have been these third parties, it seems, these field marketing organizations who were hired to do marketing and sales for some of the Medicare Advantage plans. And because they were third parties, it seems that many of them felt themselves to be excluded from CMS (Centers for Medicare & Medicaid Services) regulations and able to basically mislead prospective members with sales pitches that were highly suspect. Betsy gives some examples of these, and when you hear them, you will see why CMS is cracking down. Recouping improper payments is another area that CMS is all over. Interestingly, as Betsy Seals says in this interview, this might be one area where the government is actually ahead of private sector plans from a technology and analytic standpoint. CMS seems to have better analytics capabilities and is better at detecting fraud schemes and improper payments than the plans themselves. These plans are not sophisticated enough to notice stuff that CMS detects when it gets ahold of the plan data. But as unusual as this situation is where the government is ahead of the business sector, I can't say I'm shocked. We have had one guest on this show after another talking about just how far in the past some of these health plans are lagging. Dan O'Neill probably said it most eloquently and notably (EP359). But I digress. So, recouping improper payments has the eye of CMS. This means two things largely. It means finding “outlier” codes that some MA plan paid for but which are clearly errors and should not have been paid. Another improper payment is when plans themselves do a little fancy upcoding so that they make more money than they should in their risk-adjustment payments. This has gotten some major attention lately. Let me quote from an OIG (Office of Inspector General) report: “Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs [health risk assessments] to maximize risk-adjusted payments. We found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.” The sneaky idea here to get more money than they should from taxpayers is that someone somewhere puts down that a member has major depressive disease because someone somewhere said they did. But the patient clearly doesn't have major depressive disease because they aren't getting any treatment for it and nothing anywhere would indicate that they are suffering from a major depressive disease. So, the plan winds up getting more money from the government to care for a patient who is suffering from major depressive disease, but the patient doesn't require any additional care because they don't have major depressive disease. It's a great way to make some dollars for shareholders that is coming right out of the pockets of taxpayers. In sum, the #2 area of additional oversight is recouping improper payments either from paying claims that should not have been paid for or by wild upcoding. This is just kinda like the general sort of compliance oversight that CMS does, meaning grievances and appeals and formulary administration and models of care for SNP plans (special needs plans), compliance program effectiveness—normal stuff like this—which will be interesting given all of the articles coming out right now about how patients on Medicare Advantage plans are less likely to get more costly diabetes treatments and how often there's denials for cancer care or NCI cancer centers aren't covered, etc. One point of note here that's kind of thought-provoking on a few levels: If you're an MA plan, it is super important for you to get members in for their annual screenings. For one, CMS requires that you document diagnoses each year; and you need to do this to reduce the chances that CMS will question a treatment being paid for because there's no underlying diagnosis to support it—and these diagnoses must be re-upped every year. Recall what I was just talking about re: improper payments and fraud schemes. If a patient isn't diagnosed with something, then why are taxpayers paying for its treatment? Also risk adjustment ... if you wanna upcode, it's not a bad idea to have a diagnosis documented in multiple different ways so that when the OIG/CMS/DOJ comes knocking, you can have your ducks in a row. Getting patients in for their annual screenings is how you can safely upcode. Further, one more reason why getting patients in for annual screenings matters to MA plans, member experience counts for an increasing piece of star ratings. Patients who never see their doctor and never interact with the plan don't usually give the plan they have nothing to do with stellar marks—and besides that, these members are tough to retain. Last big deal for an MA plan to get members in for their annual is this is when the doc gets into screening for care gaps, which is also part of star measures. All this about annual screenings is a bit of a sidebar, but it is kind of interesting to contemplate as we get into the conversation today about government oversight. (For a meme on this topic, check out this Tweet from Rik Renard.) My guest, as I mentioned earlier, is Betsy Seals. Listen to our conversation about how MA plans are in the hot seat right now. Later in the fall, Betsy will be coming back to talk about trends in the Medicare Advantage marketplace. You can learn more at rebellisgroup.com. Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 08:15 What's happening with sales and marketing in the healthcare industry? 11:04 What's happening with the focus on recouping improper payments? 13:32 “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” 15:39 Are improper claim payments an administrative problem, or something more intentional? 16:20 “The health plan has a responsibility to catch those issues.” 20:10 What are specialty pharmacy prescriptions being scrutinized for? 22:12 “If this is where CMS is headed … the health plan should've already been doing this.” 23:58 Why do you see a bigger focus on social determinants of health? 25:54 Do these health plan audits actually have any teeth? 27:01 What is the biggest penalty a health plan can face from an audit? 29:57 “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” You can learn more at rebellisgroup.com. @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with sales and marketing in the healthcare industry? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with the focus on recouping improper payments? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are improper claim payments an administrative problem, or something more intentional? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The health plan has a responsibility to catch those issues.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are specialty pharmacy prescriptions being scrutinized for? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If this is where CMS is headed … the health plan should've already been doing this.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why do you see a bigger focus on social determinants of health? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Do these health plan audits actually have any teeth? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the biggest penalty a health plan can face from an audit? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento

You've Got Mail: CMS Physician Outreach and How to Respond to It

respond physicians outreach medicare centers cms got mail husch blackwell medicare medicaid services cms

Play Episode Listen Later May 25, 2022 21:25

The Centers for Medicare & Medicaid Services (CMS) has recently started mailing letters inviting physicians to one-on-one training sessions about the Medicare hospice benefit. In this episode, Husch Blackwell's Meg Pekarske, Bryan Nowicki and Claire Postman talk about what these training sessions involve, why CMS is conducting them, and how physicians and hospices can respond.

"Open Enrollment for the Health Insurance Marketplace"

Health Talks

Play Episode Listen Later May 12, 2022 30:39

Brenda Delgado from the Centers for Medicare & Medicaid Services (CMS) talks about “Open Enrollment” and what that means for communities across Illinois. Open Enrollment is the time of year when those who are uninsured or already have a plan through the Health Insurance Marketplace can shop for plans. We explore how easy it is to find quality, affordable healthcare in Illinois.

interview news healthcare illinois medical equity insurance public health centers cms primary care patient care healthcare workers health education open enrollment fqhc health insurance marketplace medicare medicaid services cms healthcare.gov

Ep. 58 Prioritizing Smooth Delivery of Customer Services

Feds At The Edge by FedInsider

Play Episode Listen Later Apr 25, 2022 59:16

If your favorite baseball site is attacked you have a mild inconvenience; if your healthcare provider gets locked out of data, then you have a serious problem. Today's discussion includes experts from the Department of Health and Human Services (HHS), the Center for Medicare & Medicaid Services (CMS), and a subject matter expert from Rubrik. They discuss the concept of improving the delivery of customer services in a world full of cyberattacks. The focus is on quick recovery if a system is compromised. Dr. John B. Murphy from Rubrik sets the stage when he says that if you look at the average time an attacker is in a network, which is subsequently compromised, it is around 70 days. What about a hospital that has surgeries scheduled and emergency room patients arriving hourly? Dr. Murphy suggests that it is a best practice to have backups that are immutable and readily accessible to maintain continuity of service for extremely sensitive networks.

health services delivery prioritizing customer service smooth rubrik human services hhs medicare medicaid services cms

2022 Health IT Regulatory & Policy Landscape

The Dish on Health IT

Play Episode Listen Later Feb 18, 2022 34:09

Pooja Babbrah, filling in as host for Ken Kleinberg, kicked off this first episode of 2022 by welcoming guest, Kim Boyd, industry consultant, regulatory and standards and Health IT expert. This episode will cover the regulatory landscape in health IT and what may be coming in 2022 from new rules to compliance and enforcement. Jocelyn Keegan, senior consultant with Point-of-Care Partners, chimed in to explain she and Kim Boyd have had a chance to work with each other on the National Council for Prescription Drug Programs, (NCPDP) electronic prior authorization (ePA) task group and that she has such admiration for her and her work. Kim Boyd then introduced herself and described how she got into regulation. She explained that while she does have a law background, having served as a paralegal in the United States Airforce, that's not where her love for policy started. In reality, the policy bug bit her in a chance encounter with a couple of entrepreneurs who mentored her and taught her their business from the ground up. In 2001, California proposed a regulation that would have been detrimental to their business, and she was asked to go up to Sacramento and talk to the regulatory bodies and legislature about why the policy wasn't good for patients or business. She was hooked from there. Pooja reaffirmed how important policy and regulation are in Health IT and pivoted the conversation by asking Kim her take on what could be expected in 2022 after several very active rules and policy years. Kim explained that many are of the mindset that Centers for Medicare & Medicaid Services (CMS) and The Office of the National Coordinator for Health Information Technology (ONC) will continue to build on the endeavors we saw over the last several years. The focus will continue to be on interoperability, data fluidity, transparency, and other areas that have already been a major focus of the industry. She went on to explain that the pandemic really helped underline the importance of solving some of these industry challenges. Kim went on to say that there is so much work left to be done to move toward full interoperability in healthcare and a merging of the clinical, administrative, and financial data. She added that she is really excited by the ONC Health Interoperability Health Outcomes 2030 initiative, stating that we need to strive toward truly collaborative and coordinated care and maybe we'll finally succeed in getting rid of faxes once and for all.Pooja followed up by asking about whether there were any pieces of legislation that have enough bipartisan support to get passed. Kim explained that there is so much we need to accomplish and, thankfully, there are a couple of areas that seem to have bipartisan support. One of those areas is health equity. Legislation looking at reimbursement models leveraging social determinants of health data and funding around standards development around social determinants of health (SDOH) are up for consideration. Kim added that she saw at least 99 pieces of legislation related to health equity for congress to take action on. Pooja then asked Jocelyn if there are any rules she hopes get published or if she has a policy wish list. Jocelyn responded by agreeing with Kim that there is so much activity going on in the policy space. One of the things near and dear to her heart is prior authorization. She recounted that at the end of 2021, ONC was making progress in certifying people around prior authorization. CMS signaled via the unified agenda that they plan to pick back up the rules that were tabled during the administration transition. Jocelyn went on to say that she hopes to see rules that align the industry on a shared path forward around prior authorization. A certain level of certainty is needed by the industry — from a policy perspective—to help spur them to pick up the implementation guides and work coming out of Da Vinci and other FHIR accelerators. Pooja asked Kim to weigh in on the future of prior authorization, specifically automating PA based on her work with CoverMyMeds and on the NCPDP ePA task group. Kim said that Jocelyn is on point. There has been an evolution in the healthcare ecosystem, especially on the medications front. CoverMyMeds has done a lot of work to move away from faxes, that there are still smaller payers that just aren't yet on board with ePA, but the needle is moving. This will be really important to ease the administrative burden for providers. If regulatory bodies require certification for ePA, that will help move the needle even further. She went on to say that as the standards bodies are evolving in their approach to automating PA, the regulatory bodies are paying attention and will hopefully issue policy that will support that work. Pooja then asked Jocelyn to weigh in on how creators of these tools can drive adoption and use outside of policies or rules to require use whether through user-based designs, establishing strong value models, or other methods. Jocelyn responded by saying that Kim touched on one of the topics earlier, which is to look at all the workflows holistically and make sure the tool being created is solving immediate problems faced by providers and giving them more information and transparency around eligibility and benefits for their patients. Before providers adopt a new tool, they are asking themselves “is this going to be better than what I'm using now?” The creators of these tools should also be evaluating their tools over time to determine what's working and what isn't and iteratively improving them. Jocelyn added that, ultimately, adoption is really a one butt in the seat at a time. It's important that any policy doesn't add additional burden to providers but, outside of policy, the creators of these tools need to ensure they are being mindful of the providers' workflows, and that the tool is usable and solving real problems. Ultimately, the reason we are in 2022 and still using faxes is that they solve the provider's immediate problem.Pooja then asked Jocelyn and Kim on how they would advise payers who work to adhere to new policies but are just checking the box and then asking “now what?”Jocelyn stated that the shift to standards-based design is a game changer. With the iterative approach of standards development at NCPDP and HL7, the standards development process is much more collaborative and iterative than in the past. Additionally, more testing is being done so the standards have already been road-tested before being named in policy. That makes it easier to meet some of these new rules. Ultimately, many of these new policies intend to unlock data, and stakeholders who are going to be successful will go beyond checking the box and will think more broadly about how this additional data can be leveraged across their organization. It's really about stakeholders mastering their data and how to best leverage the shift to APIs. Those that can take the time to do that planning, rather than just trying to meet deadlines of a new rule or piece of legislation, will be most successful. Kim agreed with Jocelyn's points, adding that while we're trying to make more data available for decision support, further upstream we're also talking about transparency. Data has to be usable and real time. The requirements from the CMS transparency & coverage final rule, the Medicare hospital outpatient perspective rule, and the No Surprises Act are all catalysts to improve the patient experience: the intent being to make us all more informed consumers. Operators in this space have a real opportunity to not only make this data more readily available to consumers but to help them understand it. We have a real health literacy issue in this country. Plans and providers need to factor this into their strategic initiative and position themselves as trusted resources for patients to better understand their data as a means to build brand loyalty. Jocelyn chimed in to say that back in July, payers all scrambled to meet the patient access API deadline. Some leapt across the line, some dragged themselves across the line. Everyone was at a different point when they started the work to meet this policy but they all met it. This step was one building block in building how we do business for the next several decades. The industry needs to take a collective breath and consider how we can set ourselves up for success and how can we move forward to make sure that each additional block we put in place is incrementally better. Jocelyn added that she and Kim both testified to a sub-group underNational Committee on Vital and Health Statistics(NCVHS) on the intersection of clinical and administrative information and talked about the needs to bring these two worlds back together. Everything ties back to the fact that to provide care, you've got to understand what the patient's coverage is. There is a relationship between care, quality, and the cost of the care. This isn't going to get fixed overnight. The idea of transparency is good but it has real-world implications on how we all do business. Pooja then shifted the discussion to cover compliance and enforcement. She mentioned that there has been a lot of shifts in deadline and delays in enforcement. Pooja asked Kim to weigh in on these shifts and changes and what stakeholders need to know. Kim relayed that although there have been delays in several rules, the policy teams and strategy teams should still be dedicated to evaluating and planning to comply. They should also be thinking about how to not only comply,but also factoring in how they can comply and how to leverage those rules to support more cost-effective use of healthcare services by both patients and providers. They should also be thinking about value-add services through these initiatives that will help build brand loyalty. Ultimately, stakeholders should be working to stay ahead of deadlines and moving forward in good faith. Jocelyn chimed in to say that many times policy guidance following legislation is really important to get the industry out of limbo. Many times, there might be abhorrent behavior as stakeholders try to meet a piece of legislation when they've misunderstood the intent or ways to really address it in a real-world setting. We should be recognizing that new policy and legislation are coming and to not panic until the final rule comes out. Because ONC and CMS are much more involved and providing some funding for some standards development, there are fewer shocks and surprises in recent policies.In an effort to close out the episode, Pooja asked both Kim and Jocelyn for last thoughts to leave with the audience. Kim conveyed that she advises everyone to just keep on pressing. If you have a policy team, work with them to align your strategic goals with policy requirements. Bring your SMEs to the table, highlight your organization successes out in the industry, work to educate and assist regulators to better understand the challenges and solutions that have shown promise. Also, work with the standards organizations and influence the standards development process which ultimately influences policy. Jocelyn's last thoughts were to point out that as the industry evolves, we are moving away from a place where only a small group of people within an organization are considered experts or in the know about interoperability but moving toward a reality where interoperability is just how we get things done. The organizations who are looking at interoperability holistically and doing the training across their organization are tightening partnerships, and really getting everyone in their organization ready to solve problems and respond to regulations. It's a much easier task when everyone in the organization has the understanding and can contribute to the solution. Pooja then closed out the first episode of 2022 by thanking Kim Boyd for joining us and to the audience for listening. She reminded the audience they can find past and future episodes on Spotify, Google Podcasts as well as HealthcareNOW Radio and other podcast carriers.

Climate Change and Cancer

ASCO Daily News

Play Episode Listen Later Feb 3, 2022 14:31

Guest host, Dr. John Sweetenham, associate director for Clinical Affairs at UT Southwestern's Harold C. Simmons Comprehensive Cancer Center, and Dr. Leticia Nogueira, a senior principal scientist in the Surveillance & Health Equity Science Department at the American Cancer Society, discuss the threat of climate change on cancer prevention and control efforts, and how oncologists can mitigate against the risks of climate change. Transcript: Dr. John Sweetenham: Hello. I'm John Sweetenham, the associate director for Clinical Affairs at UT Southwestern's Harold C. Simmons Comprehensive Cancer Center and guest host of the ASCO Daily News Podcast. Today, we'll be discussing the impact of climate change on cancer prevention and control efforts in the United States and beyond. Climate change has increased cancer risk through increased exposure to carcinogens after extreme weather events, such as hurricanes and wildfires. In addition, these major events disrupt cancer treatment, which has, until recently, poorly defined effects on cancer outcome. Dr. Leticia Nogueira, a senior principal scientist in the Surveillance & Health Equity Science Department at the American Cancer Society joins us today to discuss the threat from climate change and the importance of disaster preparedness and mitigation efforts by cancer centers. Our full disclosures are available in the show notes, and disclosures relating to all episodes of the podcast can be found at asco.org/podcasts. Dr. Nogueira, it's great to have you on the podcast today. Dr. Leticia Nogueira: Thank you. It's my pleasure to be here. Dr. John Sweetenham: Dr. Nogueira, when Hurricane Maria struck Puerto Rico in 2018, it closed several factories that provided life-saving IV fluids to US hospitals, causing shortages in cancer centers nationwide. That's really just one example of how an extreme weather event can compromise health care delivery. How is climate change impacting cancer outcomes today? Dr. Leticia Nogueira: Yes. Climate change is impacting not only the frequency, but also the behavior of extreme weather events, which makes it harder for communities and institutions to prepare and respond to these events. And disruptions in the supply chain, as we saw with Hurricane Maria, are just one example how extreme weather events can impact access to cancer care. As we saw recently with the tornadoes in Kentucky and the winter storms in Texas, extreme weather events can also damage medical infrastructure. And because cancer diagnosis and treatment can lead to several physical, psychological, and socioeconomic consequences, individuals who have been diagnosed with cancer have increased sensitivity to the health threats of climate change. Dr. John Sweetenham: Thanks. And you led a study, which was published in JAMA couple of years ago, that investigated whether hurricane disasters that occurred during the time that patients were receiving radiation therapy for non–small cell lung cancer were associated with the poorer outcome in that patient group. Could you comment on that study and, furthermore, maybe comment on whether you think that other modalities of treatment are also likely to be compromised by natural disasters? Dr. Leticia Nogueira: Yes, of course. In that study, we chose to focus on radiation therapy because it needs to be given daily, and it's highly dependent on electricity, which is frequently disrupted during hurricanes. But really, any cancer treatment modality is vulnerable to disasters that lead to power outages, supply chain disruptions, or damaged medical infrastructure, and that includes surgery, chemotherapy, immunotherapy, any cancer treatment modality. Dr. John Sweetenham: That's for sure. And I guess, also, I'm not sure whether you have any data specifically related to this, but I'd be interested to know if you have any information about the effects of these disasters on screening programs, for example, and the downstream consequences of that. That may be something that still requires study, but we'll be interested in your thoughts on that. Dr. Leticia Nogueira: Yes. That is definitely something that still requires studies. We currently don't have any publications evaluating the impact of extreme weather events on access to screening, which is a crucial stage towards the cancer care continuum. So, it starts with cancer prevention. Then, there is cancer screening, diagnosis, treatment, and survivorship. And at all of those stages, individuals have to interact with the health care system. And all of those stages are vulnerable to extreme weather events. Dr. John Sweetenham: Yeah. Yeah, I'm sure it's only a matter of time before folks really get into that because, in a way, there are parallels with the COVID-19 situation in terms of delayed screening and the potential effects of that. Some cancer centers have begun now to adapt to climate threats, and a good example of that might be by implementing plans for resilience to future flooding events. And I think many of us will vividly remember Hurricane Harvey, which had pretty devastating effects on a number of health care systems and facilities in the Houston area, including, of course, [The University of Texas] MD Anderson Cancer Center. Do you have any thoughts on whether these efforts have been successful and whether you think they're sustainable? And what do you think, for cancer centers in particular, are the most important elements of an effective disaster preparedness plan? Dr. Leticia Nogueira: Yes. [The Centers for Medicare & Medicaid Services] (CMS) requires that Medicaid- and Medicare-participating providers and suppliers develop emergency preparedness plans. However, it does not require these plans to be publicly available. So, we can't tell how many cancer treatment centers are compliant. Because these emergency preparedness plans are not shared, we also can't evaluate if these efforts have been successful, if they are sustainable, or have a pool of lessons learned from previous efforts to be able to identify the most important elements of an effective disaster preparedness plan. So, unless CMS makes these emergency preparedness plans publicly available, we just won't know. Dr. John Sweetenham: So, that's very interesting. So, if I understood you correctly, the disaster preparedness plans that health care institutions have are not publicly available. Is that correct? So, this isn't information which is readily available to researchers or anyone else who might have an interest? Dr. Leticia Nogueira: Exactly, yes. And that does not allow us to evaluate how well these are working and let other institutions learn from emergency preparedness plans that have been successful. Dr. John Sweetenham: Just carrying on that theme for one moment, are there any national benchmarks or standards that apply in that regard in terms of how those plans should look? Dr. Leticia Nogueira: CMS has guidelines about what should be included in those plans. However, there are no available data or guidelines about how each one of those guideline items need to be addressed for the emergency preparedness plan to be considered compliant. Dr. John Sweetenham: OK, interesting to know that. Just changing gear a little, one of the things that I have to confess I had not really thought about very much before I read your articles was the fact that the health care industry itself is a significant contributor to greenhouse gas emissions. And what do you think are the interventions that we, as cancer centers, could adopt to address some of the sources of greenhouse gas? Dr. Leticia Nogueira: Absolutely. So, all we have to do is look at our mission statements to realize we should be focusing heavily on climate change mitigation efforts. As a recent New England Journal of Medicine publication on decarbonizing the health care system stated, "Nowhere are the effects of climate change manifesting more clearly than in human health." And if we look at the health co-benefits of climate change mitigating efforts, this really is a no-brainer. The same air pollutants that cause the greenhouse effect also cause lung cancer and other health conditions. The health care system is the second most energy-intensive industry in the United States. Interventions aimed at improving energy efficiency and increasing use of environmentally responsible energy sources, ideally generated on site, cannot only reduce the environmental impact of cancer centers but also make them more resilient to power outages, which are becoming more frequent. Cancer centers can also switch to purchasing more environmentally responsible pharmaceuticals, medical devices, supplies, and even food. And, of course, they can reevaluate how much waste is generated and how the waste is processed. Dr. John Sweetenham: Thanks. Again, just switching gears slightly, it is clear, I think, to anyone who watches these events unfold in the media that, almost inevitably, there are health equity implications associated with climate change. And I know, on that theme, that you have been looking at the disproportionate impact of climate change on communities targeted for marginalization. Can you tell us a little more about this work? Dr. Leticia Nogueira: Yes, of course. Structural racism has concentrated in three conditions that determine vulnerability to climate change in communities that have been targeted for marginalization. These conditions are exposure, sensitivity to the health hazards of climate change, and decreased adaptive capacity. And our current project is looking at one extreme weather event at the intersection of all three, heat waves. As you probably know, government-sponsored racially discriminatory policies, such as redline, created a platform for systemic disinvestment in communities with large Black populations, leading to increased risk of exposure to climate hazards. Today, we see that historically redlined neighborhoods are disproportionately exposed to intra-urban heat, what is called urban heat islands. So that's the first one, increased exposure. But these racially discriminatory policies also led to uneven resource distribution in these communities, including limited access to full-service grocery stores, green spaces, and a clustering of alcohol outlets and tobacco marketing, leading to increased risk of developing chronic health conditions, which make you more sensitive to the health threats associated with heat waves, similar to how the health consequences of cancer diagnosis and treatment makes patients with cancer more sensitive to the health threats of climate change. So that's the second one, increased sensitivity. The last one is adaptive capacity. Material circumstances can restrict access to resources that are necessary to prepare, respond, and cope with climate hazards. Lack of properly insulated housing or access to air conditioning, for example, can limit the ability of individuals from communities targeted for marginalization to cope with heat waves. And individuals diagnosed with cancer are more likely to experience financial hardship. So, there's a parallel or an overlap here too. So, in this project, we are looking at the impact of heat waves and survival of individuals who have been diagnosed with cancer in large metropolitan areas of the United States and especially how individuals from communities targeted for marginalization might be more vulnerable. Dr. John Sweetenham: Yeah. On that note, as we wind up our discussion today, I mean, clearly, the solutions to the issues that you raise, these huge issues that you raise, are global, although we may begin with our own actions in the US, but also a long term—clearly, climate change—the fixes to climate change are very long term. But do you have thoughts on perhaps what we, in cancer centers in the US, could be doing right now as an initial step? You've mentioned disaster preparedness plans, and I take the point that that would be an important step forward, since it would incorporate reducing gas emissions and so on. But do you have any thoughts about what we should be doing immediately to begin to address this problem within our own centers and our own communities? Dr. Leticia Nogueira: Yes, of course. So definitely emergency preparedness plans if you are in a health institution is a good first step. You can also look at the energy sources that are consumed by your institution and your house. Are those environmentally responsible? And the amount of waste that is generated both at your institutions and at your community and how that waste is processed because, frequently, the waste ends up being stored and processed near communities that have been targeted for marginalization, which increases their exposure to health hazards. Another thing is to look at your purchasing processes at home and at your institution and how environmentally friendly the supply chain that leads to your consumer purchases might be impacting climate change. Dr. John Sweetenham: Well, thank you, Dr. Nogueira, for sharing your insights on this very important local and global problem and highlighting many important interventions for us to consider. It's certainly given us a lot of food for thought. So, thank you for joining us today. Dr. Leticia Nogueira: Thank you. Dr. John Sweetenham: And thank you to our listeners for your time today. If you enjoyed this episode, please take a moment to rate and review us wherever you get your podcasts. Disclosures: Dr. John Sweetenham Consulting or Advisory Role: EMA Wellness Dr. Leticia Nogueira: None disclosed. Disclaimer: The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

Medicare Reimbursement for Community Hospital Residency Programs

K&L Gates Health Care Triage

Play Episode Listen Later Jan 31, 2022 11:22

Andrew Ruskin and Gabriel Scott discuss how Centers for Medicare & Medicaid Services (CMS) has recently promulgated rules implementing the provisions of the Consolidated Appropriations Act that affect a very large number of community hospitals. Specifically, due to CMS's interpretation of Medicare graduate medical education reimbursement rules, many community hospitals are no longer eligible for these payments and don't even know it. This episode discusses the dilemma that community hospitals might be facing and emphasizes the importance of meeting a 1 July 2022 deadline CMS has imposed that may allow these hospitals to press the reimbursement “reset button.”

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Doctors Just Took a Pay Cut - VBP in 2022 with Gail Zahtz - Part 3

The #HCBiz Show!

Play Episode Listen Later Nov 23, 2021 55:13

The Centers for Medicare & Medicaid Services (CMS) released the 2022 Medicare Physician Fee Schedule and Quality Payment Program final rule on November 2, and there are big changes to physician payments. In particular, the Medicare conversion factor, which forms the basis for payments to clinicians, will be lowered by 3.7%. There's nuance in calculating the payments, but you can sum this up as most doctors will take a pay cut in 2022. And since the final rule goes into effect on January 1, 2022, doctors will begin feeling the cuts in Q1 revenue. The rule is specific to Medicare, but there are plans to push similar changes in Medicaid and we all know commercial payers tend to follow CMS' lead. We believe this change will have a ripple effect across the industry. On this episode, I talk with Gail Zahtz, CEO at PropHealth, as part of our ongoing Value-based Payment in 2022 series about what doctors can expect in terms of Medicare FFS payment come January 1, 2022. We discuss this as another example of CMS trying to make Fee-for-Service less “comfy” and expedite the move to value-based payment models. Gail helps us to understand what options exist and we lay out a framework for how to evaluate those options. This is a heavy episode, and there are no clear answers. However, there is a known direction and a viable path forward. We'll try to get you moving in the right direction. For full show notes and links: https://thehcbiz.com/177-doctors-just-took-a-pay-cut-vbp-in-2022-with-gail-zahtz-part-3/

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Episode 10: “The Impact of Healthcare API Rules in Colorado” with Kelly Taylor, Director, Colorado Digital Service

Breaking Changes

Play Episode Listen Later Aug 12, 2021 58:37

Learn about Kelly Taylor's work on healthcare APIs as part of the Colorado state government's response to a recent ruling by the Centers for Medicare & Medicaid Services (CMS).

director colorado healthcare centers apis digital services kelly taylor medicare medicaid services cms

ONC's Steve Posnack Dishes on the Transition & the Vision for Interoperability

The Dish on Health IT

Play Episode Listen Later Jan 21, 2021 40:29

Our first podcast episode of 2021 features distinguished guest Steve Posnack, Deputy National Coordinator for Health Information Technology for The Office of the National Coordinator (ONC). Our new host Ken Kleinberg along with co-hosts Jocelyn Keegan and Pooja Babbrah talk with Steve about the administration transition, FHIR, moving to APIs in healthcare and the mission to achieve interoperability. Ken first asks Steve what he expects to see from the Biden administration, more specifically, how that transition will impact ONC and Centers for Medicare & Medicaid Services (CMS) moving forward. Steve says we were set forward on a course related to the 21st Century Cures Act and there is still more to be done in implementing the statutes. Health IT has largely received bipartisan support. The technology work and how technology can be used to support healthcare to make it better is something he believes everyone is passionate about. Steve's points echoed an expected continuity of cross-party support toward areas like health IT, health data and improving the overall functioning, effectiveness, and outcomes of our nation's healthcare system through the use of technology. He did, however, expect to see a greater focus on pandemic response with the Biden administration. Ken transitions to the next topic and asks Steve and our co-hosts to give their thoughts on how we will see APIs and the work of FHIR accelerators used to support the COVID response and management of the pandemic moving forward. Steve notes the event Accelerating APIs in Healthcare: A Year in Review and Momentum for 2021 that took place on December 1, 2020, which highlights the accomplishments of four years of initiatives, investments and industry participation. He sees opportunity to continue to reduce burden and automate processes as well as work to enrich the point of care through the use of technologies and tools. Jocelyn points out that the impact of COVID, and the pandemic in general, falls into two classes when it comes to advancing APIs. We've seen some folks pull away from their progress toward value-based care due to delays in compliance dates. However, then we see some people who are no longer waiting on vendors and are understanding the role of APIs. There's nothing else that could have happened to further splay open the current state we tolerate as members of the United States' health system in terms of lack of interoperability. She says it's not about ripping out or replacing old standards, but rather, identifying where we can leverage APIs and tools we get out of FHIR to be able to sew together all these disparate parts.Pooja notes an important topic gaining attention during the pandemic: advanced care planning. People are ending up in the ER or getting intubated. It's not easy for providers to get that information for people who are ending up in the hospital. These patients may have a do not resuscitate or do not intubate order in place. It's not just the HL7 FHIR accelerators that are taking what everyone is doing around these FHIR APIs, but we're taking that and applying it in other areas. Ken asks Steve what other stakeholders who have not traditionally been involved in ONC's rulemaking will be included in future efforts. Steve says ONC's footprint is widely expansive as his office is the cross section of healthcare as a whole. The Cures Act touched on pediatrics a little bit more heavily and we've been putting out some resources in that regard. Long term post-acute care was another place that was ineligible for incentives under the original HITECH Act money. Then we have everything in between such as behavioral health, mental health, other types of specialty care that are trying to connect to your home base (primary care physician, hospital or ADT notifications). We want to make sure the care community serving patients is aware of what's going on. All of this relies on data and interoperability. Steve also mentions that pharmacy efforts around electronic prior authorization and support for opioid care and management of medication are exciting areas of work as well.An interesting topic, Ken asks Steve how industry participation helps drive ONC's rulemaking. Steve explains that most all his office's efforts are focused on longer-term visions to make lasting change, which means building relationships and establishing trust with stakeholders is essential. He says we can't regulate our way out of everything, but rather, we must get everyone on board for the same mission. Steve notes the importance of seeking knowledge from industry colleagues. Pilot testing and standards performance testing are a vital part of the process, yet he finds that it is sometimes difficult to find stakeholders to back investments.Jocelyn brings up the issue of incentivizing people so they want to become early adopters. How do we lift the ceiling for those who really want to innovate? She poses a question to Steve asking how they go about making sure that standard ceiling is lifted while at the same time making sure people are meeting the requirements of the floor. He responds by saying this is an issue they have been chipping away at for some time. It's difficult form an interoperability perspective because if two people are at very different levels, sometimes is okay, but other times there is a hard break resulting in friction. As long as it doesn't create a discrepancy in interoperability, we will allow communities to move forward with standards on a voluntary basis once their other requirements are met. To finish the podcase, Steve leaves us with an honorable mention to Project USA, something to look out for in the coming year, as well as a nod to the continuation of TEFCA and the 21st Century Cures Act in 2021.Pooja's final comments commend Steve for bringing up pharmacy. She notes there actually is a lot of work coming out of ONC that supports the pharmacy-side of healthcare. She advises her fellow colleagues in pharmacy to pay attention to the happenings of ONC and utilize them as a stakeholder in the coming year.Jocelyn ends the podcast by saying she would like to see what momentum will look like on the existing proposed rules once the dusts settle, especially with the delay around the information blocking rules themselves and what will the industry need to do to keep things moving forward.

6. Travis Broome: What's New for 2019?

israel policy centers broome accountable care organizations medicare medicaid services cms

Play Episode Listen Later Nov 18, 2018 32:09

Josh (@DrJIsrael) and Joe (@JoeShonkwiler) speak with Aledade VP of Policy and ACO Administration, Travis Broome (@Travis_Broome), about the Centers for Medicare & Medicaid Services (CMS) recently proposed regulatory changes. These include changes to the physician fee schedule and the outpatient payment system, and other regulations that will impact Accountable Care Organizations (ACOs).

4. Ahmed and Travis: Taking on Risk