The definitive inside the Beltway policy scoop for an outside the Beltway price. Click 'About' to learn more!

Affordable Care Act (ACA)

KHN: Despite ACA Protections, Out of Network Emergency Rooms Can Still Cost More
The ACA prohibits insurers from charging higher copayments for out-of-network emergency care but if a patient is admitted, they may owe out of network fees and could face "balance billing" charges.
The Hill: Pennsylvania Agrees to Expand Medicaid
PA will be the 27th state to expand Medicaid: 500,000+ persons are likely to be eligible for coverage and adults above the poverty line will be charged premiums. Also: MH$, WSJ$, WP$, NYT$, Vox, KHN
View More

Employer Sponsored Insurance

IRS: Draft Instructions for Employer Mandate-Related Information Reporting Forms Posted
The IRS posted draft instructions for completing the forms through which employers and insurers report health coverage information to employees and individuals, as well as the IRS. The ACA-driven information reporting enables employer mandate implementation and, as previously announced, filing is voluntary for tax year 2014. Drafts are posted here, including the:
  • Instructions for completing employer information reporting (here)
  • Instructions for completing insurer information reporting (here)
  • Form with instructions for recipient on employers' reporting of offers and coverage (1095-C);
  • Form with instructions for recipient for insurer reporting of health coverage (1095-B);
Also see instructions for Marketplace information reporting (here) for these purposes and the Marketplace statement with instructions for the recipient (here). Also: The Hill
NPR: Private Insurance Companies Sponsoring End of Life Care Conversations Raises Ethical Concerns
Insurers can hire private companies to call patients with complex conditions to discuss end-of-life care decisions. Ethicists have raised issue with conflicting interests and phone-only relationships.
View More

Doctors

Modern Healthcare: Providers Hesitant to Participate in Medicare's Pioneer ACO Model
Physician participation in Medicare's ACO models varies: with higher risks and lower opportunity for financial gain, doctors are gravitating less to the Pioneer model than to Medicare Shared-Savings.
NYT: AMA Encourages Medicare to Reimburse for End of Life Counseling
AMA submitted codes to Medicare to create reimbursement for end of life medical planning. Medicaid in CO and OR recently began covering these services and private insurers are as well. Also, MH ($)
View More

Prescription Drugs

FDA: Information Collection: Drug Compounding Outsourcing Facility Fees
The FDA is accepting comments for 30 days on a proposed information collection within its guidance on drug compounding outsourcing facility registration fees. The agency has submitted the proposed information collection for OMB approval. In the notice, it outlines comments received in an earlier comment request and includes burden estimates for reporting activities pertaining to the establishment fee, reinspection fees and dispute resolution requests.
Reuters: Takeda, Lilly Lose Bid to Overturn Punitive Damage Case
In a consolidated multidistrict federal case, Takeda and Lilly lost their a bid to overturn a combined $9 billion punitive damage fine for hiding cancer risks of Actos drug. Also, Bloomberg
View More

Medicaid – General

Vox: Governor Indicates Tennessee May Expand Medicaid
Gov. Haslam indicated that TN may submit a proposal to HHS later this year in order to expand Medicaid under the ACA. 162,000 Tennesseans could become eligible for coverage if Medicaid is expanded.
Vox: 10 Non-expansion States Leave 3.6 Million Uninsured
Between Texas, Florida, Georgia, North Carolina, South Carolina, Missouri, Alabama, Virginia, Tennessee, and Oklahoma opting out of Medicaid expansion 3.6 million people are left uninsured.
View More

Health Information Technology (HIT)

CMS: Meaningful Use Rule Finalizes Delay of Stage 3 to '17, with Stage 2 Extending through '16 for Early Adopters; Finalizes '14 Flexibility in Certified EHR Editions
CMS and ONC issued a final rule under which providers in the Medicare and Medicaid EHR Incentive Program can meet Meaningful Use (MU) in 2014 using 2011 or 2014 Edition certified EHR technology (CEHRT), or a combination, with flexibility to attest to either Stage 1 or 2 objectives and measures if they faced delays in 2014 Edition CEHRs’ availability. Furthermore, as proposed, CMS finalizes the delay of Stage 3 of MU until 2017. Stage 2 now extends through 2016 for eligible professionals and hospitals who began the program in 2011 or 2012. Specifically:
  • A chart in an accompanying fact sheet outlines the 2014 options now available to providers, including if they were slated to demonstrate Stage 1 or Stage 2 in 2014, based on the Edition of CEHRT they are using.
  • Among the examples, a provider scheduled to attest to Stage 2 in 2014 who is using 2014 Edition CEHR technology can attest to 2014 Stage 1 objectives and measures, provided they “could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability,” or Stage 2 objectives and measures.
  • The agency specifies that “all eligible professionals, eligible hospitals, and CAHs are required to use the 2014 Edition CEHRT in 2015.”
  • CMS elaborates on what is meant by “not able to fully implement [2014 Edition CEHRT]” and “delays in 2014 Edition CEHRT availability,” the criteria for leveraging the flexibility for using the varying options for CEHRT  outlined for 2014. For instance, the agency notes that it “stress[es] the delay in 2014 Edition CEHRT availability must be attributable to the issues related to software development, certification, implementation, testing, or release of the product by the EHR vendor which affected 2014 CEHRT availability, which then results in the inability for a provider to fully implement 2014 Edition CEHRT.” On inability to fully implement, it says “this area where we intended to provide the broadest application” and, on p. 42, notes several examples that would not be permissible instances, adding “we believe that beginning with what is not permissible, rather than what is, represents a far smaller set of circumstances that will both quell providers’ concerns about audits and provide additional parameters on the use of the CEHRT options generally.”
The agency says that in finalizing the rule, “we have heard [providers’] concerns over the challenges of successfully implementing 2014 Edition CEHRT in time for an EHR reporting period in 2014.” Citing widespread reports of “EHR development and implementation delays,” CMS says it disagrees with stakeholders who commented that the changes “somehow give providers that waited until the last minute a ‘free pass’, or punish those providers who were early adopters.” Additionally, the final rule:
  • Finalizes revisions for the Stage 2 MU objective for hospitals to providing “electronic laboratory results to ambulatory providers; to correct the regulation text for the measures associated with the objective for hospitals to provide patients the ability to view online, download, and transmit information about a hospital admission; and to set a case number threshold exemption for CQM reporting applicable for eligible hospitals and critical access hospitals (CAHs) beginning with FY 2013”; and
  • Formally adopts the Data Element Catalog and the Quality Reporting Document Architecture Category III standards with updated versions of these standards.
The final rule takes effect on Oct. 1, 2014. Also: Modern Healthcare($), The Hill, Inside Health Policy($)
AHRQ: Health Information Exchange Effective Health Care Program
AHRQ is seeking information to assist its review of the Health Information Exchange by the Evidence-based Practice Centers under the AHRQ Effective Health Care (EHC) Program. The EHC Program is intended to identify "as many studies as possible that are relevant to the questions for each of its reviews." AHRQ is "supplementing the usual manual and electronic database searches of the literature by requesting information from the public (e.g., details of studies conducted) [and is] looking for studies that report on Health Information Exchange, including those that describe adverse events."
View More

Health Insurance Exchanges

AP: Tax Forms Could Pose Challenges
Individuals purchasing ACA coverage through an exchange must file a 1095-A form indicating proof of insurance as well as the total amount of subsidies received. Exchanges to send forms to consumers.
Inside Health Policy: Treasury Indicates Cap for Repayment of Excess Premium Subsidies
Repayment of excess ACA advance tax credit payments is likely to be capped at $300-$2500 depending on income and filing status. Congress originally limited the recapture to $400 per family. Also: KHN
View More

Hospitals

Modern Healthcare: Providers Hesitant to Participate in Medicare's Pioneer ACO Model
Physician participation in Medicare's ACO models varies: with higher risks and lower opportunity for financial gain, doctors are gravitating less to the Pioneer model than to Medicare Shared-Savings.
CMS: Meaningful Use Rule Finalizes Delay of Stage 3 to '17, with Stage 2 Extending through '16 for Early Adopters; Finalizes '14 Flexibility in Certified EHR Editions
CMS and ONC issued a final rule under which providers in the Medicare and Medicaid EHR Incentive Program can meet Meaningful Use (MU) in 2014 using 2011 or 2014 Edition certified EHR technology (CEHRT), or a combination, with flexibility to attest to either Stage 1 or 2 objectives and measures if they faced delays in 2014 Edition CEHRs’ availability. Furthermore, as proposed, CMS finalizes the delay of Stage 3 of MU until 2017. Stage 2 now extends through 2016 for eligible professionals and hospitals who began the program in 2011 or 2012. Specifically:
  • A chart in an accompanying fact sheet outlines the 2014 options now available to providers, including if they were slated to demonstrate Stage 1 or Stage 2 in 2014, based on the Edition of CEHRT they are using.
  • Among the examples, a provider scheduled to attest to Stage 2 in 2014 who is using 2014 Edition CEHR technology can attest to 2014 Stage 1 objectives and measures, provided they “could not fully implement 2014 Edition CEHRT for the EHR reporting period in 2014 due to delays in 2014 Edition CEHRT availability,” or Stage 2 objectives and measures.
  • The agency specifies that “all eligible professionals, eligible hospitals, and CAHs are required to use the 2014 Edition CEHRT in 2015.”
  • CMS elaborates on what is meant by “not able to fully implement [2014 Edition CEHRT]” and “delays in 2014 Edition CEHRT availability,” the criteria for leveraging the flexibility for using the varying options for CEHRT  outlined for 2014. For instance, the agency notes that it “stress[es] the delay in 2014 Edition CEHRT availability must be attributable to the issues related to software development, certification, implementation, testing, or release of the product by the EHR vendor which affected 2014 CEHRT availability, which then results in the inability for a provider to fully implement 2014 Edition CEHRT.” On inability to fully implement, it says “this area where we intended to provide the broadest application” and, on p. 42, notes several examples that would not be permissible instances, adding “we believe that beginning with what is not permissible, rather than what is, represents a far smaller set of circumstances that will both quell providers’ concerns about audits and provide additional parameters on the use of the CEHRT options generally.”
The agency says that in finalizing the rule, “we have heard [providers’] concerns over the challenges of successfully implementing 2014 Edition CEHRT in time for an EHR reporting period in 2014.” Citing widespread reports of “EHR development and implementation delays,” CMS says it disagrees with stakeholders who commented that the changes “somehow give providers that waited until the last minute a ‘free pass’, or punish those providers who were early adopters.” Additionally, the final rule:
  • Finalizes revisions for the Stage 2 MU objective for hospitals to providing “electronic laboratory results to ambulatory providers; to correct the regulation text for the measures associated with the objective for hospitals to provide patients the ability to view online, download, and transmit information about a hospital admission; and to set a case number threshold exemption for CQM reporting applicable for eligible hospitals and critical access hospitals (CAHs) beginning with FY 2013”; and
  • Formally adopts the Data Element Catalog and the Quality Reporting Document Architecture Category III standards with updated versions of these standards.
The final rule takes effect on Oct. 1, 2014. Also: Modern Healthcare($), The Hill, Inside Health Policy($)
View More

Quality

CMS: Archived Sessions Address FQHC PPS, Physician Quality Feedback Reports
CMS posted materials from recent sessions that provided an overview of operational requirements for the federally qualified health center prospective payment system (video slideshow) and guidance on interpreting PQRS-driven Supplemental Quality and Resource Use Reports (transcript).
CMS: Blog: Using ACA Lever, OR Group Uses Medicare Data for Transparency Efforts
The Oregon Health Care Quality Corporation (Q-Corp) became the first to issue a public report incorporating data gleaned through the ACA's qualified entity program, which enables certain organizations to obtain Medicare data for use in transparency initiatives. A CMS official notes that the data enabled more comprehensive quality reporting, adding that "the Medicare data has also allowed Q-Corp to publish quality measures for clinics that did not have a large enough patient population for reporting using only commercial and Medicaid data."
View More

Legal

WSJ: Judge Temporarily Blocks Abortion Law in Louisiana Requiring Hospital Privileges
Federal judge is allowing abortion providers to continue providing services while they establish hospital privileges within 30 miles of their practice, as required by a Louisiana law. Also: NYT$, Reut
The Hill: District Judge Rules Texas Abortion Law Unconstitutional
Judge ruled that requiring abortion providers to meet ambulatory surgical center requirements places an “unconstitutional undue burden” on women. Also: MH ($), NYT ($), Bloom ($), LA, NPR, KHN
View More

Delivery Reform

Commonwealth: Report: Strategies to Integrate Physical and Behavioral Health in Medicaid
This report reviews strategies states have used to integrate mental and behavioral health through administrative integration, purchasing, and licensure/certification regulations in Medicaid.
CMS: Analysis: Physician Group Practice Demo Drove "Small Reductions" in Medicare Costs
A study finds that 10 demo sites collectively achieved 2% in cost savings per assigned beneficiary per year over the 5-year period, with improved performance on 6 of 7 process-of-care quality metrics and net per capita savings of 0.8% to the Medicare program. Savings stemmed largely from reductions in inpatient use. Noting model design similarities between the Physician Group Practice demo and ACA-driven Medicare ACOs, researchers conclude that "judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings." They add that "nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program."
View More

Prevention

WH: White House Calls on Federal Labs to Take Immediate Action to Secure Infectious Agents
Following breaches with anthrax, small pox, and other highly contagious elements at CDC and NIH laboratories in recent months, the White House ordered federally funded labs handing infectious agents to review safety protocols and conduct an inventory of pathogens. Also: Reuters
CDC: Pediatric Vaccination Rates Remain High But Vary Geographically
As reported in the Morbidity and Mortality Weekly Report, infant vaccination rates increased or remained stable for all routinely recommended vaccines in 2013: more than 90% of children received certain vaccines and less than 1% of infants were unvaccinated. The CDC continues to express concern that children are not receiving immunizations according to the recommended timeline and rates vary significantly by state. Nationwide rates were as follows: over 90% for measles, mumps, and rubella (MMR), poliovirus, hepatitis B and varicella; 73% for rotavirus; 83% for 1 or more doses of hepatitis A; 74% for Hepatitis B. Colorado, Ohio and West Virginia have some of the lowest vaccination rates while New Hampshire has some of the highest. All rates are based on data from the CDC’s 2013 National Immunization Survey for children ages 19-35 months. Also: Reuters
View More

FREE TRIAL

If you like what you see here, get a FREE 30-DAY all-access pass to Healthcare Lighthouse. Lighthouse Beacon will elevate and illuminate your understanding of Federal health policy, at an unbeatable price. TRY IT FREE FOR 30 DAYS.

Not only will you unlock access to all components of our site, including ACA Explained, CRS Vault, LightSearch and the Event Calendar, you’ll get a daily snapshot of the key press clips, regulatory updates and other developments driving your day through LightNews Daily.

START YOUR FREE TRIAL TODAY or CONTACT US for multi-user discounts. Additional discounts may be available for academic and charitable institutions.

Learn More

View More