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Affordable Care Act (ACA)

Vox: An Overview of Aid-In-Dying Laws
5 states have aid-in-dying laws: OR, WA, NM, VT and MT. Oregon's law, the oldest, allows physicians to prescribe terminally ill patients a lethal dose of sedatives that the patient can self-administer
The Hill: Catholic College to Get Reprieve from Birth Control Fines
While Ave Maria University's lawyers fight the ACA's birth control mandate in court, the university will not have to pay millions of dollars in fines under a new temporary injunction.
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Employer Sponsored Insurance

CMS: FAQs: Reinsurance Contribution Process, Including Payment, Number of Covered Lives
CMS clarifies that an "ACH debit transaction through is the only vehicle being accepted for reinsurance contributions payment for the 2014 Benefit Year" (here). Also see an FAQ on the payment schedule for third parties making reinsurance contributions on behalf of contributing entities (here), as well as an FAQ on situations in which employer reinsurance contributions are not required (here). CMS also addresses logistical issues in generating the number of covered lives for which reinsurance contributions apply (e.g, here and here). Also see here on payment schedule options.
Reuters: EEOC Files Lawsuit Regarding Wellness Program
In the agency's 3rd lawsuit challenging a corporate wellness program, the EEOC is suing Honeywell International Inc to bar the them from penalizing employees that opt out of wellness program testing.
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Vox: An Overview of Aid-In-Dying Laws
5 states have aid-in-dying laws: OR, WA, NM, VT and MT. Oregon's law, the oldest, allows physicians to prescribe terminally ill patients a lethal dose of sedatives that the patient can self-administer
Robert Wood Johnson Foundation: Study: Analysis of Health Plan Network Design in 6 Cities
Report finds network size is not always linked to premium cost, but narrow networks frequently offer affordable prices. Each hospital in the cities studied was included in at least one exchange plan.
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Prescription Drugs

Vox: An Overview of Aid-In-Dying Laws
5 states have aid-in-dying laws: OR, WA, NM, VT and MT. Oregon's law, the oldest, allows physicians to prescribe terminally ill patients a lethal dose of sedatives that the patient can self-administer
Reuters: FDA Approves Two-in-One Diabetes Pill
Xigduo XR, the first once-daily tablet combining an inhibitor drug and metformin, was approved by the FDA. The drug is made by the British drugmaker AstraZeneca.
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Medicaid – General

Avalere: Analysis: Election Could Influence Medicaid Expansion in 6 States
Gubernatorial races in AK, FL, GA, KS, ME and WI will shape whether these states move forward with Medicaid expansion. State legislatures will also impact what transpires. Also: MH$, CQ$, IHP$, USA
NYT: ACA Insurance Expansion: A County-by-County Look at the Rate of Uninsured
County-level examination indicates low income counties saw the greatest drops in the rate of uninsured following the ACA, with particular gains for young adults, minorities and rural areas. Also: Vox
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Health Information Technology (HIT)

Reuters: For Eczema, Telemedicine is Just as Effective as Office Visits
A year long study demonstrated that patients with eczema who emailed photos of their skin and communicated with dermatologists online, saw just as much improvement as those who went into the office.
Modern Healthcare: DeSalvo Leaves ONC, Joins Ebola Team
Dr. DeSalvo, HHS' National Coordinator for HIT, is departing the position and will serve as the Acting Assistant Secretary of Health for the Ebola response team.
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Health Insurance Exchanges

Reuters: Private Insurers Anticipate Significant Enrollment Growth
Based on feedback from potential customers, insurers expect to sell 20-50% more qualified health plans during the next open enrollment period beginning Nov. 15. Also: LA, Blm$, IHP$, KHN
Inside Health Policy: CMS to Release New Data Showing Decline in Individuals with Inconsistencies
Updated statistics regarding the number of individuals with data matching issues on their exchange applications are expected soon. Agency officials indicated a "steep decline" from earlier estimates.
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Robert Wood Johnson Foundation: Study: Analysis of Health Plan Network Design in 6 Cities
Report finds network size is not always linked to premium cost, but narrow networks frequently offer affordable prices. Each hospital in the cities studied was included in at least one exchange plan.
CMS: Study Estimates Care Costs Stemming from Certain Hospital-Acquired Conditions
Looking at 6 hospital-acquired conditions (HACs) across 90-day episodes, the researchers estimate that additional care costs totaled $146M annually compared with costs if the HACs were prevented. They write that these costs are "well in excess of the roughly $19.5M in DRG payment reductions that was documented for these 6 HACs in 2010, following the implementation of the HAC-[present on admission] program." They note that the ACA's HAC payment cuts are a "much more significant payment penalty than the HAC-POA program." HACs examined in the study include: severe pressure ulcers; fractures; catheter-associated urinary tract infections; vascular catheter-associated infections; surgical site infections following certain spinal, shoulder, or elbow procedures; and deep vein thrombosis or pulmonary embolism following hip or knee replacements.
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CMS: Medicare Payments to Home Health Agencies to Decrease by 0.3% or $60M in CY15
CMS issued a final rule enumerating CY15 payments under the Medicare home health prospective payment system. The net -0.3% payment update reflects -2.4% due to the second year of the 4-year phase-in of the ACA-mandated rebasing adjustments; 2.1% CY 2015 payment update (based on the 2010-based HHA market basket (MB) update of 2.6%, less the 0.5% statutorily-mandated productivity adjustment); 0% proposed CY 2015 wage index; and  0% CY 2015 case-mix weights (this “recalibration” uses “most current cost and utilization data available, in a budget neutral manner,” CMS notes). Other key provisions of the proposed rule include:
  • 60-day Episode Rate Rebasing: CMS finalizes its proposal to implement the second year of the 4-year phase-in of the rebasing adjustments to the national, standardized 60-day episode payment amount, the national per-visit payment rates, and the non-routine medical supply (NRS) conversion factor (CF) pursuant to section 3131 of the ACA. Generally consistent with the proposed rule, the final rule “implements increases to the national per-visit payment rates, a 2.82% reduction to the NRS conversion factor, and a reduction to the national, standardized 60-day episode rate of $80.95 for CY 2015.” CMS concludes that the final CY 2015 national, standardized 60-day episode payment is $2,961.38.
  • Face-to-Face Requirements: Seeking to “reduce administrative burden and provide home health agencies with additional flexibilities in developing individual agency procedures for obtaining documentation supporting patient eligibility,” CMS finalizes three changes to the ACA face-to-face requirements for home health episodes beginning on or after Jan. 1, 2015, including eliminating the current narrative requirement (CMS notes that the “narrative requirement continues to apply to services furnished during episodes that begin before Jan. 1, 2015”). The agency adds that “the certifying physician would still be required to certify that a face-to-face patient encounter occurred and document the date of the encounter as part of the certification of eligibility,” adding that “for medical review purposes, we will require documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) to be used as the basis for certification of patient eligibility.” Secondly, the agency finalizes that “associated physician claims for certification/re-certification of eligibility (patient not present) will not be eligible to be paid when a patient does not meet home health eligibility criteria.” Thirdly, it clarifies that “a face-to-face encounter is required for certifications, rather than initial episodes,” elaborating that “a certification (versus recertification) is considered to be any time that a new Start of Care OASIS is completed to initiate care.” In an accompanying information collection estimate, CMS projects that the cumulative effects of its changes to face-to-face requirements will drive an “estimated net reduction in burden for certifying physicians of 192,765 hours or $21,796,330 (see Tables 39 and 40 on p. 233-234 of the public inspection copy), with “a one-time burden for HHAs to revise the certification form of 5,761 hours or $245,397.”
  • Home Health Value-based Purchasing: Referencing a number of comments received on the agency’s proposal to extend a value-based purchasing (VBP) program to HHAs in CY 2016 – similar, in some respects, to the Hospital VBP model but one whereby there would be a 5-8% payment adjustment in the 5-8 states selected to participate in the prospective HHA VBP model – the agency indicates that it will continue “to review these comments as it considers testing a HHA VBP model.” CMS notes that “[a] HHA VBP model presents an opportunity to test whether larger incentives would lead to higher quality of care for beneficiaries,” indicating that if the agency “decides to move forward with the implementation of an HHA VBP model in CY 2016, [CMS] intends to invite additional comments on a more detailed model proposal to be included in future rulemaking.”
  • Home Health Quality: Among the changes to the HH quality reporting program, CMS finalizes a proposal to establish a minimum threshold for submission of OASIS assessments for purposes of quality reporting compliance. According to CMS, “HHAs that do not submit quality measure data to CMS will see a 2% reduction in their annual payment update (APU)…Beginning in CY 2015, the initial compliance threshold will be 70%. This means that HHAs will be required to submit both admission and discharge OASIS assessments for a minimum of 70% of all patients with episodes of care occurring during the reporting period. CMS will increase the compliance threshold over the next two years to reach a maximum threshold of 90%.”
  • Therapy Assessments: CMS finalizes its proposal to simplify therapy reassessment regulations by “eliminat[ing] the therapy reassessments that are required to be performed on or ‘close to’ the 13th and 19th  therapy visits.” CMS notes further that it is “also finalizing that a qualified therapist (instead of an assistant) from each discipline provide the needed therapy service and functionally reassess the patient…at least once every 30 calendar days, rather than at least every 14 calendar days, as proposed.”
The fuller final rule enumerates additional provisions, including those related to rate-setting changes (including a recalibration of the HH PPS case-mix weights to reflect CY 2013 HHA claims data, as well as Core Based Statistical Area (CBSA) changes), in addition to revisions to the Medicare conditions of participation (CoPs) for speech-language pathologists, among other changes. A CMS fact sheet is available here. Also: Congressional Quarterly ($)
CMS: Updated FAQs on Hospice Item Set Posted
CMS recently posted an updated Q&A document pertaining to the Hospice Item Set (HIS) pursuant to the agency’s broader Hospice Quality Reporting Program (HQRP) mandated by the ACA. As CMS notes, the updated “reflects frequently asked HIS-related questions that were received by the Quality Help Desk during the third quarter (July through September) of 2014.”
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CMS: Update: Reversal of Polysomnography Demand Letters
CMS says MACs' "demand and recover" letters for suspected polysomnography overpayments have been suspended and that providers should not appeal because "all claim denials will be reversed."
Bloomberg: Johnson & Johnson to Pay $250 Million to Settle 1,000 More Hip Suits
1K claims were excluded from a $2.5 billion settlement of similar claims last year over a hip device failure and now the device manufacturer may pay more than $250 million to resolve additional claims
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Delivery Reform Bulletin: Care Delivery Opportunities for Beneficiaries with Substance Abuse Disorders
CMS seeks states interested in participating in a Medicaid Innovation Accelerator Program (IAP) focused on caring for beneficiaries with substance use disorders (SUDs). Its bulletin describes plans for a "high-intensity, data-driven IAP Learning Collaborative centered on SUD system reforms." The agency also identifies delivery and benefit reforms where states could improve SUD-related care.
Commonwealth: Reports: Lessons from the Safety Net Medical Home Initiative
3 issue briefs discuss findings from the Initiative: 1) medical home transformation takes years (report), 2) peer learning is helpful (report), and 3) committed leadership is key (report).
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USPTF: Final Research Plan: Screening for Obstructive Sleep Apnea
The plan lays the groundwork for a systematic evidence review and updated preventive service recommendation on screening's use in adults. Following a comment period on the draft plan, the Task Force "inserted an additional key question addressing multistep screening approaches and an additional contextual question about interventions to enhance adherence" to continuous positive airway pressure treatment. It also "expanded and clarified the descriptions of the eligible population, screening tests, and outcomes" of screening.
IOM: Report: Policies to Invest in the Health of Young Adults
This provides federal, state, and local policy leaders, employers, nonprofits, and other community partners "guidance in developing and enhancing policies and programs to improve young adult health."
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