Literature Review

New study calls home health star ratings into question McKnights Home Care, by Adam Healy, 4/11/24A comparison of agency-reported functional measures and claims-based hospitalization measures raises doubts about the value of star ratings as a means of evaluating home health agency (HHA) quality. The study, published Wednesday in JAMA Network Open, analyzed differences between claims-based and agency-reported outcomes for nearly 23 million patient episodes before and after the introduction of the star ratings system to compare changes over time. 

5 most challenging requirements in 2023 [for hospitals]: Joint Commission Becker's Clinical Leadership, by Mackenzie Bean; 4/3/24Maintaining infection prevention and control during disinfection and sterilization activities was the most challenging compliance standard for hospitals in 2023, according to The Joint Commission. The organization identified the top five requirements for which hospitals were most frequently out of compliance, based on surveys and reviews from Jan. 1 through Dec. 31. ... [Click on the title's article for the 5 top challenges.]

Elevating quality, outcomes, and patient experience through Value-Based Care: CMS Innovation Center’s Quality PathwayNEJM Catalyst; by Susannah M. Bernheim, MD, MHS; Noemi Rudolph, MPH; Jacob K. Quinton, MD, MPH; Julia Driessen, PhD; Purva Rawal, PhD; and Elizabeth Fowler, PhD, JD; 4/3/24The U.S. Center for Medicare and Medicaid Innovation is launching a new Quality Pathway to elevate patient-centered quality goals in the design and evaluation of alternative payment models. The Quality Pathway will align model design around quality goals; elevate outcomes and experience measures, particularly patient-reported outcomes; and ensure that evaluations have the ability to assess the impact of models on primary quality goals. These determinations will help the Innovation Center make critical decisions about which models to scale or expand in the pursuit of improving the quality of care for people with Medicare and Medicaid.

CMS finalizes 2025 Medicare Advantage rates Becker's Payer Issues, by Rylee Wilson; 4/1/24 CMS finalized a slight decrease in Medicare Advantage benchmark payments for 2025. The agency published its final rate notice for 2025 April 1. The final rule was largely similar to CMS' proposed payment rates issued in January. The agency will cut benchmark payments by 0.16% from 2024 to 2025. CMS estimated plans will see 3.7% higher revenue overall in 2025. MA risk score trend of 3.86% — the average increase in risk adjustment payments year over year — will offset risk model revisions that will lead to a 2.45% decline in revenue and a projected decline in star rating bonuses, according to the agency. 

Nearly half of health systems are considering dropping Medicare Advantage plans Becker's Hospital CFO Report, by Andrew Cass; 3/22/24 ... "HFMA Health System CFO Pain Points Study 2024" is based on a survey of 135 health system CFOs conducted in January.  According to the report, 16% of health systems are planning to stop accepting one or more Medicare Advantage plans in the next two years. Another 45% said they are considering the same but have not made a final decision. 

New legislation proposes national expansion of integrated care modelsHealth Affairs, by Laura M. Keohane; 3/20, 24 This article is the latest in the Health Affairs Forefront major series, Medicare and Medicaid Integration. The series features analysis, proposals, and commentary that will inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.  ... On March 14, a bipartisan group of senators—members of the Senate Duals Working Group—released legislation (The DUALS Act: Delivering Unified Access to Lifesaving Services Act of 2024) that commits to ambitious goals for aligning Medicare and Medicaid coverage ... Would the integration measures proposed in this bill be more successful [than previous programs] in achieving these goals? This Forefront article highlights the key components of the legislation and assesses its ability to advance better outcomes for dual-eligible beneficiaries.

Maryland health officials have applied for new federal ‘AHEAD model.’ Here’s what it means. Maryland Matters, by Danielle J. Brown; 3/20/24State health officials have placed their bid for Maryland to be among the first participants in a federal program that will help fund state initiatives to improve patient outcomes and bridge inequities, while constraining hospital and medical costs. The U.S. Centers for Medicare and Medicaid Services (CMS) is rolling out the new States Advancing All-Payer Health Equity Approaches and Development Model, called the AHEAD Model, and states are invited to apply for funding. 

Medicare Advantage health equity factor to shake up ratings Modern Healthcare, by Nona Tepper; 3/20/24 A federal effort to promote health equity will redistribute billions of dollars in Medicare Advantage Star Ratings bonus payments among health insurance companies. Beginning in 2027, the Centers for Medicare and Medicaid Services will reward Medicare Advantage plans that demonstrate progress addressing health disparities. At the same time, the agency scrapped a bonus policy that benefited insurers that sustained high overall quality ratings over time. 

Personal care workers received most Medicaid fraud convictions in 2023: OIG McKnights Home Care, by Adam Healy; 3/15/24 More personal care workers were convicted for Medicaid fraud than any other provider type last year, according to a new report released Thursday by the Department of Health and Human Services Office of the Inspector General. OIG found that 279 personal care services (PCS) attendants were convicted of Medicaid fraud in 2023 — far more than the next four highest provider types combined. These convictions amounted to more than $10.5 million in criminal charges. 

Dual eligibles, PACE expansion bill draws bipartisan support, industry endorsements McKnights Home Care, by Adam Healy; 3/18/24A bipartisan group of senators introduced legislation that would improve care coordination for dual-eligible beneficiaries and expand the Program of All-Inclusive Care for the Elderly to a larger share of people. The legislation’s primary function would be to require every state to develop a comprehensive, integrated health plan for dual-eligible beneficiaries, according to a summary. The bill also would require every state to allow PACE programs to be established, open up enrollment to any time in a given month, and extend PACE coverage to people under 55 years of age. 

Care Alternatives, whistleblowers resolve hospice fraud suitBloomberg Law, by Daniel Seiden; 3/15/24

Whistleblower cases on the rise nationwide; Sarbanes-Oxley, Dodd-Frank laws open door for more to speak out PressReader, Herald-Tribune; by Esteban Parra and Xerxes Wilson; 3/10/24A former medical director specializing in neurosurgery at southern Delaware's largest health care provider claims in a lawsuit that Bayhealth Medical Center misclassified "brain-dead" patients in order to overbill for services. 

How CON laws influence hospice quality, program integrityHospice News, by Holly Vossel; 3/8/24Variations in hospice certificate of need (CON) state laws are raising program integrity concerns.Notable mentions: Susan Ponder-Stansel, President and CEO of Alivia Care; Paul Ledford, President and CEO of the Florida Hospice & Palliative Care Association; Eddie Belluomini, COO of 1Care Hospice & 1Care Kids; Paula Sanders, Executive Director of the Georgia Hospice and Palliative Care Organization; Matt Hansen, Executive Director of the Homecare & Hospice Association of Utah.