Literature Review

Vital Signs: Digital Health Law Update | Spring 2024 Jones Day - Vital Signs; by Vital Signs' Editors; July 2024Welcome to Vital Signs, a curated compilation of the latest legal and regulatory developments in digital health.  [Topics include the following:]

How well does Medicare cover end-of-life care? It depends on what type Medical Xpress; by Mark Harden, CU Anschutz Medical Campus; 7/19/24 Not all versions of Medicare are created equal—and when it comes to end-of-life care, some versions may serve a patient's needs better than others. That's the focus of newly published research by Lauren Hersch Nicholas, Ph.D., MPP, a University of Colorado Department of Medicine and CU Cancer Center health economist, and her colleagues. The researchers analyzed the experiences of more than a million people receiving Medicare-funded services in the last six months of their lives. ... Their paper was published July 19 in JAMA Health Forum. What Nicholas and her colleagues found is that the kind of Medicare a patient is enrolled in can make a difference in whether that patient gets certain treatments, and whether the patient dies in a hospital or in hospice care.

Does Medicare pay for dementia care? Here’s what coverage you can expect for treatments and therapies Aol - Fortune; by Margie Zable Fisher; 7/18/24 Age-related memory loss is common, but more serious memory problems may be a sign of dementia, which is not a normal part of aging. ... Dementia patients have a variety of medical issues. “In addition to symptoms related to dementia, the overwhelming majority of dementia patients have one or more chronic health conditions,” says Matthew Baumgart, Vice President of Health Policy, at the Alzheimer's Association. Medicare (and Medicare Advantage) provide some coverage for dementia, beginning with the diagnosis, says Baumgart. [Click on the title's link for practical, user-friendly information about what Medicare provides arose the trajectory of dementia's progression. CMS's new GUIDE pilot program is described.]

The Medicare Post-Acute Care and Hospice Provider Public Use File (PAC PUF)CMS press release; 7/10/24[This file] provides information on services provided to Medicare beneficiaries by home health agencies (HHAs), hospices, skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs).  It contains information on demographic and clinical characteristics of beneficiaries served, professional and paraprofessional service utilization, submitted charges, and payments at the provider, state, and national levels.  Additionally, the PAC PUF includes payment information at the case-mix grouping level for HHAs, SNFs, and IRFs.

[CMS CAHPS Hospice Survey] Agency Information Collection Activities: Submission for OMB Review; Comment Request Federal Register; A Notice by the Centers for Mediare & Medicaid Services; 7/9/24 Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: CAHPS Hospice Survevy; Use: CMS launched the development of the CAHPS Hospice Survey in 2012. Public reporting of the results on Hospice Compare started in 2018. The goal of the survey is to measure the experiences of patients and their caregivers with hospice care. 

All the payment factors included in the 2025 Home Health Proposed Rule Home Health Care News; by Joyce Famakinwa; 7/8/24 Providers examining the 2025 home health proposed payment rule may be experiencing some déjà vu, according to William A. Dombi, the president of the National Association for Home Care & Hospice’s (NAHC). “Much of what we see in the rule is just, on the payment side of it in particular, an update from ‘23 and ‘24,” he said during a recent webinar hosted by NAHC. On June 26, the U.S. Centers for Medicare & Medicaid Services (CMS) unveiled its home health proposed payment rule for 2025. The proposal includes a payment decrease in the aggregate by 1.7%, or by about $280 million. “That needs qualification,” Dombi said. “That’s $280 million, not to what it would otherwise have been, but rather, in contrast to what it’s expected to be for 2024.” Providers examining the proposed rule will also see a 2.5% net inflation rate update. ... 

Long-term care providers among 193 criminally charged, $2.75 billion in fraud recoveries so far in 2024McKnight's Senior Living; by Kathleen Steele Gaivin; 7/1/24The Justice Department has recovered more than $2.75 billion in false claims against healthcare providers and charged 193 defendants so far this year in criminal cases through its 2024 National Health Care Fraud Enforcement Action, and many of the cases involve nursing homes, home health or hospice agencies, and assisted living providers, according to a Thursday report from the department’s criminal division.

Survey: Adults dropped from Medicaid after pandemic faced healthcare access, affordability issues CIDRAP - Center for Infectious Disease Research & Policy Research and Innovation Office, University of Minnesota; by Mary Van Beusekom, MS; 7/2/24 A survey of low-income adults in four southern US states shows that nearly half of those disenrolled from Medicaid after COVID-19 pandemic protections ended had no insurance in late 2023, leading to struggles to afford healthcare and prescription drugs and threatening to broaden a gap that had narrowed during expanded governmental benefits. The data were derived from 89,130 adult residents of Arkansas, Kentucky, Louisiana, and Texas participating in the National Health Interview Survey in 2019, 2021, and 2022. In 2023, states rechecked Medicaid eligibility after COVID-19 governmental protections expired, disenrolling millions. The average participant age was 48.0 years, and 51.6% were women. Researchers from Beth Israel Medical Center and Harvard Medical School published the results late last week in JAMA Health Forum.

CMS: Advance health equity through accessibility CMS.gov; posted for July 2024 Throughout July, the Center for Medicare & Medicaid Services Office of Minority Health (CMS OMH) celebrates Disability Pride Month and the anniversary of the Americans with Disability Act (ADA). Twenty-seven percent of adults in the United States have some type of disability, with mobility (serious difficulty walking or climbing stairs) and cognitive (serious difficulty concentrating, remembering, or making decisions) disabilities being the most prominent types. Individuals living with disabilities often face worse overall health outcomes, including likelihood of obesity (41.6%), diabetes (15.9%), and heart disease (9.6%). ... Find these resources on our health observance page this month or our Improving Access to Care for People with Disabilities page all year long.

DOJ slaps $20M opioid prescription penalty on OptumRx Fierce Healthcare; by Noah Tong; 7/2/24 OptumRx will pay $20 million to resolve claims the company violated the Controlled Substances Act by improperly filling certain opioid prescriptions, the Department of Justice recently announced. The agency claims OptumRx did not fill prescriptions correctly for "trinity prescriptions" like benzodiazepines and other muscle relaxants from April 2013 to April 2015. These prescriptions, which are addictive, may not have been “intended for legitimate medical use” and carry “significant risk of harm,” according to a news release. “Pharmacies providing opioids and other controlled substances have a duty under the Controlled Substances Act to ensure that they fill prescriptions only for legitimate medical purposes,” said Principal Deputy Attorney General Brian Boynton, head of the Justice Department’s Civil Division, in a statement. “The department will continue to work with its law enforcement partners to ensure that pharmacies do not contribute to the opioid addiction crisis.”

Lawmakers say CMS should ban Medicare Advantage’s use of AI to deny care McKnights Long-Term Care News; by Josh Henreckson; 6/26/24 The Centers for Medicare & Medicaid Services should consider banning artificial intelligence from being used to deny Medicare Advantage coverage pending a “systematic review,” a group of 49 congressional leaders is urging. ...  Skilled nursing providers have been sounding the alarm for years on Medicare Advantage coverage access, especially when informed by AI and other algorithms. Sector leaders have frequently noted that these methods can deny or prematurely end coverage for patients who need it to afford necessary long-term care. Providers and consumer advocates both spoke out in favor of the lawmakers’ letter this week. “LeadingAge’s nonprofit and mission driven members … have firsthand experience of Medicare Advantage (MA) plans’ inappropriate use of prior authorization to deny, shorten and limit MA enrollees’ access to medically necessary Medicare benefits,” wrote Katie Smith Sloan, president and CEO of LeadingAge. ... “Implementation by [the] Centers for Medicare and Medicaid Services (CMS), which we fully support, would ensure MA plans fulfill their obligation to provide enrollees equitable access to Medicare services.”

Optum to pay $20M to settle improper prescription allegations Becker's Hospital Review; by Rylee Wilson; 6/28/24 OptumRx will pay $20 million to settle allegations it improperly dispensed some opioid medications, the Justice Department said June 27. The settlement resolves an investigation into if OptumRx improperly filled certain opioid prescriptions between 2013 and 2015. The Justice Department alleged the pharmaceutical benefit manager improperly dispensed opioids in combination with other drugs, including benzodiazepines and muscle relaxants, from its mail-order pharmacy operations in Carlsbad, Calif. Opioids prescribed alongside benzodiazepines and muscle relaxants are commonly referred to as "trinity" prescriptions. These prescriptions raise red flags that the drugs may not be for legitimate medical use, and could lead to the diversion of controlled substances, the Justice Department said. In its investigation, the department alleged OptumRx dispensed trinity prescriptions without resolving red flags. OptumRx does not admit liability as part of the settlement.

‘Lot of work to be done’: What home health leaders expect from payment rulemaking in 2024Home Health Care News; by Joyce Famakinwa; 6/24/24 In recent years, home health care has faced relentless cuts from the Centers for Medicare & Medicaid Services (CMS). It has plagued the industry, but providers and advocates alike are still hopeful a light at the end of the tunnel is ahead. ... Home Health Care News recently caught up with PQHH CEO Joanne Cunningham and David Totaro, the president and executive director of Hearts for Home Care. ... [Cunningham said,] "I anticipate that what we will see, given CMS’s posture and prior rulemaking cycles, is the continuation of the policy that will put in place permanent cuts to the Medicare home health program. We’re bracing ourselves for an additional sizable permanent cut. We don’t know exactly what CMS has planned for the temporary cuts, otherwise known as the clawback cuts. We will certainly see, at a minimum, CMS identify what their new projected value of the temporary cuts are. ...