Closing racial and ethnic gaps in access to care

By Cara V. James, Director of the Office of Minority Health

Did you know that 31% of Hispanics are uninsured, compared to 12% of non-Hispanic whites?  Or that less than one-third of African American adults with diabetes receive the recommended services?  Or that fewer than 40% of American Indian and Alaska Native adults over 50 have gotten screened for colorectal cancer?

April is National Minority Health month. Although we continue to make strides in improving health outcomes, it’s clear that racial and ethnic minorities, low-income Americans, and other underserved populations still lag behind the general population.  Racial and ethnic minorities often have higher rates of serious diseases, are less likely to get preventive care, and have fewer treatment options and less access to quality health care. They’re also less likely to have health insurance than the general population.

The Affordable Care Act is improving access to care for minority populations and other underserved groups in a variety of ways. The Affordable Care Act fills in current gaps in coverage for the poorest Americans by creating a minimum Medicaid income eligibility level across the country.  Beginning in January 2014, individuals under 65 with incomes below 133 percent of the federal poverty level will be eligible for Medicaid, so for the first time, low-income adults without children will be guaranteed coverage through Medicaid in every state.  Medicaid and Children’s Health Insurance Program eligibility and enrollment will be much simpler and will be coordinated with the newly created Affordable Insurance Exchanges.

Starting in 2014, Affordable Insurance Exchanges will make buying health coverage easier and more affordable. These new Exchanges will offer one-stop shopping so individuals can compare prices, benefits and health plan performance on easy-to-use websites. Financial help will be provided to low-income populations, which will help ensure that all Americans have access to quality, affordable health coverage, even if they lose a job, switch a job, move, or become ill.

The Affordable Care Act is also improving access to preventive care services. Research shows that use of preventive services is traditionally lower for minority populations, but now all people with Medicare can get a range of recommended preventive serviceswithout paying part B coinsurance or meeting the deductible.  These include certain tests for breast, colorectal, and other cancers, diabetes, cardiovascular disease screening, and intensive behavioral therapy for obesity.  A new benefit, a yearly wellness visit with your qualified and participating doctor, has also been added, and is also available without part B cost sharing. These free preventive services can help reduce health disparities and give everyone the chance to enjoy better health and a better quality of life.

People with Medicare also get a 50 percent discount on covered brand-name drugs while in the prescription drug coverage gap (known as the “donut hole”), and by 2020, the donut hole will be closed. This change will help relieve the financial burden for millions of seniors and people with disabilities across the country.

The health of racial and ethnic minorities is one of the focus areas for the Office of Minority Health at CMS.  OMH works not only to serve as a resource and liaison within and outside of CMS, but to help improve CMS minority health data, report on CMS progress in reducing disparities, and represent minority health interests in all CMS activities.

The gaps in health outcomes won’t change overnight. But with free preventive services, yearly wellness visits, and more affordable prescription drugs, we’re helping to increase access to care, reduce health disparities, and strive for health equity.

7 Ways to Protect Yourself from Medical Identity Theft

Peter Budetti, MD, JD, Deputy Administrator for Program Integrity

Fraud affects everyone. We’ve said it before – but this time we’re not just talking about people with Medicare. As my colleague Dr. Shantanu Agrawal and I pointed out in a recent article in the Journal of the American Medical Association, physicians are also vulnerable to a type of fraud called “medical identity theft.”

Medical identity theft happens when a fraudster uses your unique medical identifiers to bill insurance for items or services that you never provided or prescribed. Examples of these medical identifiers could be your National Provider Identifier (NPI), Tax ID Number (TIN), and medical licensure information. You pay for this kind of fraud with increased financial liabilities – you may be expected to pay taxes on earnings you never received, or repay insurance companies for payments on items or services that you never provided. You may also become the physician of record for services you had nothing to do with.

How to Protect Yourself

1. Keep your medical information up-to-date. Report any changes to Medicare, Medicaid, and other insurance companies, such as opening and closing of offices and moving between group practices.
2. Review billing notices. Actively review your Medicare remittance notices to make sure there are no items or services listed that you didn’t provide, including payments to you for services you didn’t provide.
3. Protect your medical information. There are things you can do to better protect your information. For example, before giving out your medical identifiers to potential employers or other organizations, check them out to be sure they’re legitimate. Only give your information to trusted sources.
4. Train your staff. Make sure your employees know the proper way to use and distribute your medical information, such as on prescription pads, electronic health records, and on other important documentation.
5. Educate your patients. Patients are victims, too. Medical identity theft leads to higher insurance costs. Also, if patients are charged for items or services they never received, they may be denied in the future when they really need them. Tell patients to be on the lookout for fraudulent activity on their explanation of benefits statements, and how to report fraud when they see it.
6. Report any suspected medical identity theft. If you believe you may have been the victim of identity theft, call the CMS program integrity investigative contractor in your region,which you can find at this location: http://www.cms.gov/MedicareProviderSupEnroll/downloads/ProviderVictimPOCs.pdf You may also report any suspected cases of medical identity theft to the Office of the Inspector General.
7. Protect your prescription pads. Keep your prescription pads in a safe and secure environment, so they can’t be used by fraudsters to obtain prescriptions you never prescribed.

Medicare fraud and identity theft affects everyone. That’s why it’s very important for all of us to work together to stop it.

2012: the Year of Meaningful Use

Marilyn Tavenner and Farzad Mostashari

Health IT plays a central role in building a 21^st century health care system—where care is safer, better coordinated and patient-centered, where we pay for the right care, not just more care. Increasing the adoption and use of Health IT is crucial, so we’ve set an ambitious goal for 2012: get 100,000 health care providers paid under the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs by year’s end. For us to succeed, we need you—the states and our many other health IT partners—to join us in this effort.

The EHR incentive programs, which began in 2011, give payments to eligible professionals, eligible hospitals, and critical access hospitals as they adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. “Meaningful use” means providers need to show they’re using certified EHR technology in ways that improve care.

Health IT systems, including EHRs, help providers communicate better with each other about patient care, which reduces medical errors, helps cut down on paperwork, and cuts out needless duplicate screenings and tests. These all lead to better coordinated patient care and lower health care costs.

Thanks to the invaluable work of Health IT coordinators, Medicaid programs, Health IT regional extension centers (RECs), leading hospitals, public health departments, and other stakeholders, CMS and ONC made significant progress in getting providers to adopt and use EHRs during 2011:

• Over $2 billion in Medicare EHR Incentive Program payments were made between May 2011 and the end of February 2012.
• More than $1.8 billion in Medicaid EHR Incentive Program payments were made between January 2011 (when the first set of states launched their programs) and the end of February 2012.
• More than 59,000 eligible professionals and over 2,000 eligible hospitals have been paid by the Medicare and Medicaid EHR Incentive Programs.
• More than 120,000 providers, representing approximately 40 percent of primary care providers nationwide, enrolled with the RECs to get program information and help in adopting EHRs.

There’s every reason to expect that together we can increase these numbers greatly this year to reach our target of 100,000 providers. Working together with state Medicaid programs and CMS Regional Offices, many states are partnering with local stakeholder organizations to make sure providers get the help and encouragement to achieve “meaningful use,” and assistance with overcoming any barriers that are blocking their progress. Several states have already set ambitious targets:

•  Ohio has set a goal of having 10,000 providers receive EHR incentive payments in 2012, representing nearly 40 percent of all eligible professional and eligible hospitals in the state.
•  Washington State aims to have more than 7,000 providers receive EHR Incentive payments this year representing about 40 percent of the state’s eligible professionals and eligible hospitals.
•  California has set goals of 10,000 eligible providers receiving Medicaid payments and $500 million in incentive payments coming to the state by June.
•  New York State has set an initial target of over 6,000 eligible providers receiving incentive payments in calendar year 2012.

Many of our provider partners have stepped up to the challenge as well.  The National Association of Community Health Centers, the American Academy of Pediatrics, and the American Association of Family Physicians have engaged their memberships in achieving meaningful use in 2012.  The American College of Cardiology has set its own goal of 8,000 cardiologists by 2012 – one third of its membership!

By working together, the health IT community can make 2012 the Year of Meaningful Use.

Stage 2 Meaningful Use NPRM Moves Toward Patient-Centered Care Through Wider Use of EHRs

Farzad Mostashari, MD, ScM, National Coordinator for Health Information Technology

Marilyn Tavenner, Acting Administrator for the Centers for Medicaid and Medicare Services

Substantial evidence shows that higher adoption of Electronic Health Records (EHR) can save our health care system money, save time for doctors and hospitals, and save lives.  Thanks to the Recovery Act and the Medicare and Medicaid EHR Incentive Program, we have seen great success and momentum as we’ve taken the first steps toward adoption of this critical technology: to date, over 43,000 providers have received $3.1 billion to help make the transition to electronic health records; the number of hospitals using EHRs has more than doubled in the last two years from 16 to 35 percent between 2009 and 2011; and 85 percent of hospitals now report that by 2015 they intend to take advantage of the incentive payments.

We have just announced the second stage of the three stage process.  This reflects our desire to create ambitious, but achievable, goals that enable eligible professionals and hospitals to make incremental progress in adopting and implementing electronic health records (EHRs).  The three stages are:

• Stage 1 (which began in 2011 and remains the starting point for all providers): “meaningful use” consists of transferring data to EHRs and being able to share information, including electronic copies and visit summaries for patients.
• Stage 2 (to be implemented in 2014 under the proposed rule): “meaningful use” includes standards such as online access for patients to their health information and electronic health information exchange between providers.
• Stage 3 (expected to be implemented in 2016): “meaningful use” includes demonstrating that the quality of health care has been improved.

Today’s proposed rules focus on using EHRs to improve health and health care while reducing the burden on physicians and hospitals where possible. 

CMS’ proposed rule would specify the Stage 2 criteria that eligible providers must meet in order to qualify for Medicare and/or Medicaid EHR incentive payments.  It also would specify Medicare payment adjustments that, beginning in 2015, providers will face if they fail to demonstrate meaningful use of certified EHR technology and to meet other program participation requirements.  In addition, as we announced in a November 2011 “We Can’t Wait” announcement, Stage 1 has been extended an additional year for providers who attested in 2011 – meaning that these providers will have to attest to Stage 2 in 2014, instead of in 2013. 

The proposed rule announced by ONC identifies standards and criteria for the certification of EHR technology, so eligible professionals and hospitals can be sure that the systems they adopt are capable of performing the required functions to demonstrate either stage of meaningful use that would be in effect starting in 2014.

Together, these rules will encourage even more providers to participate and support more coordinated, patient-centered care. 

For details on today’s announcement, please visit

http://www.cms.gov/apps/media/press_releases.asp;

http://www.cms.gov/apps/media/fact_sheets.asp; and

www.healthit.gov/policy-research.

Fighting Improper Payments And Fraud – Protecting Taxpayer Dollars

By Marilyn Tavenner, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS)

Fighting fraud and waste in the health care system is a top priority for the Obama Administration.  We are committed to using all resources at our disposal in these efforts – and they are paying off.

Just last week, the Departments of Justice and Health and Human Services (HHS) released an updated annual report showing that in FY 2011 anti-fraud efforts have recovered more than $4.1 billion in fraudulent Medicare payments – the second year in a row recovery efforts reached this unprecedented level.  Compare this to just $2.14 billion recovered in FY 2008.  Prosecutions are way up too:  the number of individuals charged with fraud increased from 821 in fiscal year 2008 to 1,430 in fiscal year 2011 – nearly a 75 percent increase.

But we know we need keep doing more to end the “pay and chase” model of fighting fraud.  We need to stop fraud and waste from happening in the first place.  Today we’re taking an important step to protect taxpayer dollars by reducing improper payments to Medicare Advantage plans, an action that is estimated to save $370 million in the first audit year alone.  By improving the way we audit Medicare Advantage contracts, we will reduce the payment error rate for the Medicare Advantage program  and that saves money for Medicare.

We are also using new, advanced techniques to fight fraud.  Starting last year, we have been using “predictive modeling” technology – similar to technology used by credit card companies to identify and fight fraud nationwide.  This effort is just getting started but it’s already making a difference. Since the predictive modeling system was activated, CMS has stopped, prevented or identified $20 million in payments through November 2011 that should not have been made.

In addition, predictive modeling has identified 2,500 leads for further investigation, 600 preliminary law enforcement cases under review and resulted in 400 direct interviews with providers who would not have otherwise been contacted.

Predictive modeling won’t reach its full potential in overnight, but it’s already making an incredible difference and will do even more in the weeks, months and years ahead.

Better Coordination Leading to Swifter Medicare Coverage and Access

Marilyn Tavenner, Acting Administrator, Centers for Medicare and Medicaid Services 

Today, CMS is proposing that Medicare patients across the country have access to a new procedure, known as “transcatheter aortic valve replacement.” 

The result of an unprecedented level of collaboration between CMS, the Food and Drug Administration (FDA), the Agency for Healthcare Research and Quality (AHRQ), the American College of Cardiology, the Society of Thoracic Surgeons and Edwards Lifesciences, this proposed National Coverage Determination continues CMS’ commitment to cross-agency collaboration and ensuring patients have access to the latest and best medical technology.

Aortic valve replacements are used in patients whose aortic heart valves are damaged and cause the valve to narrow – a condition known as “aortic stenosis.” Once patients experience symptoms of aortic stenosis, treatment is critical to improve their chances of survival.  Until recently, aortic stenosis has been treatable only through surgical aortic valve replacement.  And as our population ages, the number of Americans with aortic stenosis progressively increases. 

Transcatheter aortic valve replacement allows doctors to replace a patient’s aortic valve through a small opening in the leg.  This less invasive procedure gives patients who cannot undergo open heart surgery a new way to repair their damaged heart valve.    

The first transcatheter aortic valve replacement system was approved by the FDA on November 2, 2011.  Since then, we have worked closely with the FDA, AHRQ, the American College of Cardiology, the Society of Thoracic Surgeons, and the device manufacturer, Edwards Lifesciences, to bring this new procedure to Medicare enrollees across the country.

Because this technology is still relatively new, it is important that these procedures are performed by highly trained professionals in optimally equipped facilities.  This decision proposes “coverage with evidence development” which, as a condition of coverage, would require certain provider, facility, and data collection criteria to be met.  Such requirements are important to ensure beneficiaries receive the safest and most appropriate care.

We are hopeful that this proposed decision will lead to increased access to less invasive treatment options for Medicare beneficiaries and save lives.

Today’s proposed decision will be open for 30 days of public comment before CMS issues a final decision later this year.  To read the proposal, visit the CMS website at: http://www.cms.gov/medicare-coverage-database/details/nca-proposed-decision-memo.aspx?NCAId=257

23 States Recognized for Success – Getting More Eligible Children Enrolled in Health Coverage

by Cindy Mann, CMS Deputy Administrator and Director, Center for Medicaid and CHIP Services  

Families across the country are experiencing hard times. The good news is that, despite the challenges States themselves are facing, many States are moving forward to adopt strategies that help get more eligible children enrolled in Medicaid and CHIP and stay enrolled for as long as they qualify.  We are working hard, together with the states, to keep children’s health coverage a high priority.

We are pleased to be able to recognize and support states that are improving their programs and are enrolling more children in health coverage as a result.  Performance Bonuses, authorized by the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), were designed to reward states for making access to health coverage easier for eligible children and signing up more children who qualify.

This year, 23 states qualified for CHIPRA Performance Bonuses totaling nearly $300 million. States were eligible for a bonus if they reached targets for the number of additional children enrolled in Medicaid, and if they took steps to simplify their enrollment and renewal processes, adopting at least five out of eight options.  In addition to providing an incentive for States to make lasting positive changes to their programs, the performance bonuses help offset the added costs of insuring the lowest income children.

Of the states that earned bonuses, seven are new this year: Connecticut, Georgia, Montana, North Carolina, North Dakota, South Carolina, and Virginia. And, many of the states that have received bonuses in the past haven’t stopped improving their programs – five of these states implemented a sixth strategy in an effort to further streamline procedures.

The states awarded performance bonuses for the first time have simplified enrollment and renewal in a variety of ways.  For example:

• Georgia is using information from the WIC program to make Medicaid enrollment simpler, using the “express lane eligibility” option.
• Virginia has simplified the eligibility renewal process so that children have an easier time keeping their coverage when it’s time to renew.
• North Carolina and North Dakota both guarantee eligible children enrollment for a full year, to be sure they get continuous coverage and don’t lose access to care.
• Montana and Connecticut have adopted the “presumptive eligibility” option, which jump-starts enrollment for children who appear eligible and lets them see a doctor or get a prescription while their full eligibility is being determined.

These and other activities to simplify the process and enroll eligible children are paying off:  New data from the CDC’s  National Center for Health Statistics found that an additional 1.2 million children have gained health insurance coverage since CHIPRA was signed into law in 2009. This increase has been entirely due to greater enrollment in public programs such as Medicaid and CHIP.

Learn more about CHIPRA – and find out what states and communities are doing to get more eligible children covered.

As Open Enrollment Ends, People with Medicare save $1.5 billion on prescriptions

by Kathleen Sebelius

If you’ve had a Medicare Advantage or Prescription Drug Plan for a few years, you’ll know that December is the end of Medicare Open Enrollment.  This year, the last day for you to choose new Medicare health or prescription drug coverage for 2012 is December 7, earlier than it’s been in previous years.

December 7 is tomorrow.  But you still have until midnight tomorrow if you want to make a change  to your medical or prescription drug coverage.

And as you are reviewing your plan, remember that Medicare is only getting stronger. New data released today shows how millions of seniors have gotten cheaper prescription drugs and free preventive services, all thanks to the President’s health reform law.

Thanks to the Affordable Care Act, the Medicare prescription drug coverage gap known as the donut hole is starting to close. Through the end of October, 2.65 million people with Medicare have received discounts on brand name drugs in the donut hole.  These discounts have saved seniors and people with disabilities a total of $1.5 billion on prescriptions – averaging about $569 per person.  For State-by-State information on the number of people who are benefiting from this discount in 2011, visit this page.

Over the coming years, the Affordable Care Act will help close the coverage gap completely. Each year from now to 2020, you’ll pay less for brand name and generic drugs in the coverage gap.  And in 2020, the coverage gap will be eliminated and the donut hole will be closed for good.

In addition to cheaper prescription drugs, the Affordable Care Act also made preventive services available to people with Medicare for free. Preventive care helps people stay healthy and live longer lives. Through the end of November nearly 24.2 million people with Medicare have received one or more free preventive services, including Medicare’s new free Annual Wellness Visit.  For State-by-State information on the numbers of people who are utilizing preventive services in 2011, visit this page.

These new benefits are just two ways the Affordable Care Act is making Medicare and our health care system stronger and giving hardworking families the security they deserve. It has helped lower your Part B premium in 2012 by $22.  And, on average, Medicare Advantage premiums will be lower in 2012 as enrollment continues to rise.

And if you haven’t reviewed your Medicare coverage, take time now to compare your current coverage with other options to make sure your plan will meet your health care needs for the coming year.  Medicare now offers better choices, more benefits, and lower costs thanks to the Affordable Care Act. Visit www.Medicare.gov/open-enrollment/ for more information.

Better quality of life and improved health care for individuals living with HIV

By Don Berwick, M.D., Administrator of the Centers for Medicare & Medicaid Services

Today, we celebrate the vast improvements in treatments and the quality of life for individuals living with HIV.  This day serves as a reminder of the many accomplishments in fighting AIDS during the past three decades, but also highlights how much more work we have left in fighting this disease.

Thanks to major advances in science and medicine, people living with HIV face a much different reality today.  In 1981, when AIDS first emerged in the US, the disease was equivalent to a death sentence. Now, thirty years later, people with HIV who receive medication and proper care live longer, healthier lives — just as they could with any other chronic illness.

Despite the powerful arsenal at our disposal, some of our best defenses remain out of reach for a significant proportion of the more than 1.2 million Americans living with HIV. An estimated 30 percent of this group does not have health coverage of any kind. As a result, they have no way to cover the cost of medications and treatment that we know are life-preserving.

We took an important step to remove this barrier this past summer. The Centers for Medicare & Medicaid Services (CMS), in collaboration with, the Health Resources and Services Administration (HRSA), and the Centers for Disease Control (CDC), released new guidance that encourages States to take advantage of important Medicaid options that will help improve care for individuals living with HIV.

These options can make it easier for States to prevent or delay the institutionalization of people living with HIV and can help people living in nursing homes or other institutions transition back home when they are able. States can expand Medicaid access to low-income people living with HIV, enabling them to become eligible for services without having to be considered permanently disabled due to an AIDS diagnosis. States can provide more effective, earlier treatment of HIV by making available a limited or comprehensive package of services, which may include anti-retroviral therapies or case management to ensure adherence to treatment.  Better coordinated care opportunities were also made available to support physical and behavioral health and linkages to long-term supports for individuals with multiple chronic conditions through the state option to establish health homes.

This epidemic has claimed the lives of 600,000 Americans.  We can and are doing more to slow transmission of the disease and to ensure people living with HIV have access to the health care that will help them lead longer and healthier lives. I am confident of the positive quality of life effects that these options will make for Medicaid beneficiaries living with and fighting through HIV/AIDS every day.