Literature Review

CMS - Roadmap to Better Care: Tribal Version CMS; 6/17/24This version of the Roadmap has been updated to help members of the American Indian and Alaskan Native community connect to their health care, including benefits provided through the Indian Health Service (IHS), Medicare, Medicaid, Marketplaces, or private insurance. Unlike Medicare, Medicaid, the IHS is not an insurance program or an established benefits package. IHS cannot guarantee funds are available each year, and as a result sometimes needs to prioritize patients of greatest need. The preservation of legacy, heritage, and traditions is vital. This roadmap is designed to help sustain cultural richness and strengthen the well-being of present and future American Indian and Alaska Natives for generations. To learn more about enrollment in Marketplace, Medicare, or Medicaid see pages 4 and 5 or visit ihs.gov/forpatients.

CMS: Home healthcare spending estimated to grow by 7.1 percent from 2025 to 2026, surpassing other sectorsMcKnight's Home Care; by Adam Healy; 6/12/24National spending on home healthcare is projected to grow faster than any other health sector in the years ahead, according to newly published data from the Centers for Medicare & Medicaid Services’ Office of the Actuary [see Health Affairs: National Health Expenditure Projections, 2023-32: Payer Trends Diverge As Pandemic-Related Policies Fade]. Between 2025 and 2026, national spending on home health care is expected to increase by 7.1%, a data analysis published Wednesday in HealthAffairs revealed. Projected spending growth in home health care should outpace all other categories including hospital care services (4.9%), physician and clinical services (4.8%) and nursing homes care (4.8%), and it is expected to grow even faster during the following years. Between 2027 and 2032, the sector will see spending growth of 8.1%, compared to hospital spending (5.6%), physician and clinical services (5.5%) and nursing home care (6%). In 2022, home health spending increased by roughly 6%, CMS disclosed in a previous report.

Medicare Advantage members spend over $2,500 less than traditional Medicare enrollees annually: StudyBecker's Payer Issues; by Jakob Emerson; 6/10/24Medicare Advantage enrollees spend more than $2,500 less on healthcare costs on average than traditional Medicare enrollees, according to an independent analysis by ATI Advisory. The analysis was commissioned by the Better Medicare Alliance and published June 10. It used data from the Medicare current beneficiary survey and cost supplement files from 2019 to 2021. Six key takeaways:

Red River Valley expands services for dual-eligible populationsHospice News; by Holly Vossel; 6/11/24North Dakota-based Hospice of the Red River Valley is focused on expanding its home- and community-based services among dual-eligible Medicare and Medicaid populations in need of greater support. Serious and terminally ill patients in lower socioeconomic and underserved regions face several competing challenges in accessing health care, according to Tracee Capron, executive director at Hospice of the Red River Valley. Developing a sustainable care delivery model that better addresses unmet needs among patients and their families requires significant investment, Capron said. 

Returning to the community: Health care after incarceration: A guide for health care reentryCMS; 6/6/24This joint publication by CMS and the U.S. Department of Justice Office of Justice Programs helps people recently released from incarceration take charge of their health, connect to health services, and find additional resources. It is available in Spanish on the Access Care webpage and more languages are coming soon.

NAHC, NHPCO comment on revision of Hospice Certifying Physician Enrollment RequirementHomeCare; 6/7/24 The National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO) responded to the Centers for Medicare & Medicaid Services (CMS) recently revised guidance regarding the implementation of the hospice certifying physician enrollment requirement. NAHC and NHPCO identified that some instruction provided by CMS was inconsistent with established law and regulations regarding the certification of a patient’s terminal illness for new hospice elections after the first benefit period. That instruction, if implemented, could have resulted in major negative impacts on hospices and the patients and families they serve. Both organizations requested that CMS retract the guidance to remain consistent with regulation and statute. On June 6, CMS rescinded its guidance in order to align with current regulations, offering clarity for providers. 

3 keys to hospice oversight preparation Hospice News; by Jack Silverstein; 6/4/24 When hospice providers are being investigated not just by CMS but the FBI, the stakes for compliance are higher than ever. In May of 2024, the federal law enforcement agency placed its spotlight on the rising number of complaints about hospice fraud, in which hospices participate in signing up seniors for care without the seniors’ knowledge. Integrity concerns are in four states: Arizona, California, Nevada and Texas. The mechanics vary but the end result is the same: hospices getting paid for services they either did not provide, provided at a substandard level or had no authority to provide at all. ...

Reap what you sowFraud of the Day; by Larry Benson; 6/4/24Newly released Federal Trade Commission data show that consumers reported losing more than $10 billion to fraud in 2023, marking the first time that fraud losses have reached that benchmark. This marks a 14% increase over reported losses in 2022. The short of this report is that there is more opportunity in fraud than ever before. And fraudsters don’t care who they are scheming from. Including the dying. Shiva Akula owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in Louisiana and Mississippi. ... Between January 2013 and December 2019, Akula billed Medicare approximately $84 million in fraudulent claims. He was paid approximately $42 million relating to these fraudulent claims. And leaving the dying to just do that. Die without the extra care he profited from. ... [Akula was sentenced to serve 20 years in prison and to repay $42 million in fraudulent Medicare billing claims.]

Hospice Certifying Physician edit in effectAAPC - American Academy of Professional Coders; by Rebecca Johnson; 6/3/24 The Centers for Medicare & Medicaid Services (CMS) and its Home Health and Hospice (HHH) Medicare Administrative Contractors (MACs) are all systems go for the new — and potentially troublesome — claims system edit. The edit went into effect June 3. ... In the 2024 Hospice Payment Rate Update final rule, CMS adopted a requirement that two categories of physicians must be enrolled in or validly opted out of Medicare for hospice services to be paid: the hospice medical director or the physician member of the hospice interdisciplinary group; and the attending physician that certifies the patient for hospice. CMS did at least grant hospices’ requests for an implementation delay at that time, moving the deadline from the proposed Oct. 1, 2023, to May 1, 2024. Then, on the eve of that start date, CMS bumped the edit for one more month. ...

To guard themselves from sanctions, home health agencies need to invest in QAPI programs, NAHC experts say McKnights Home Care; by Adam Healy; 5/22/24 To protect themselves against the Centers for Medicare & Medicaid Services’ compliance enforcement mechanisms, home care providers must focus on quality assessment and performance improvement (QAPI) programs, experts at the National Association for Home Care & Hospice said during a webinar. ... Earlier this month, the Centers for Medicare & Medicaid Services released updates to its enforcement remedies and alternative sanctions for home health and hospice agencies. These remedies and sanctions may be imposed in lieu of termination for providers with condition-level deficiencies. They include civil money penalties, payment suspensions, temporarily-appointed management, directed plans of correction or in-service training.

Health equity: Insights on the CMS Framework and Leadership in HealthcareCHAP Podcast; by CHAP and Marisette Hassan; 5/23/24As a nurse, witnessing the pervasive disparities in healthcare access was a profound wake-up call. Our conversation with Marisette Hassan takes us on a journey through the challenges and aspirations of achieving health equity, a mission that has never been more critical than in the shadow of the COVID-19 pandemic. When systems fail to serve everyone equally, the consequences are dire, and our discussion underlines the urgency of this issue. With Marisette's insights on the CMS health equity framework, we unpack the layers of this complex issue, from the importance of data collection to the necessity of culturally tailored services.

Humana, Aetna likely to lose Medicare Advantage members Modern Healthcare; by Nona Tepper and Lauren Berryman; 5/14/24 Industry heavyweights CVS Health Aetna and Humana foresee Medicare Advantage membership losses next year. Anticipated changes to health plan offerings and benefit design to achieve long-term business profitability could mean losing a significant portion of their Medicare Advantage membership, executives told investors at the Bank of America Securities Healthcare Conference on Tuesday. ... Headed into next year, Aetna may adjust benefits, tighten its prior authorization policies, reassess its provider networks and exit markets, CVS Health Chief Financial Officer Tom Cowhey told investors.  ... [Humana Chief Financial Officer Susan Diamond] anticipates losing about 5% of its 6.1 million Medicare Advantage members, ... Conversely, UnitedHealth Group’s UnitedHealthcare insurance business appears to be better positioned for growth heading into 2025 ... , executives said. UnitedHealth Group CEO Andrew Witty said, ... “The thing we don't want is unsustainable ups and downs in our performance in any particular regard. ... You should just expect more of the same from us in terms of what we’re doing.” 

Nurse practitioners improve skilled nursing's dementia care outcomes, but regulatory barriers remain: studyMcKnights Long-Term Care News; by Josh Henreckson; 5/13/24[Nurse pracitioners'] NPs’ involvement can significantly improve end-of-life care outcomes for residents with Alzheimer’s disease and related dementias (ADRD), according to the results of a new study in JAMA Health Forum. ... Those benefits, however, were shrunk by state regulations on the scope of care NPs are allowed to provide. ...  Elizabeth White, PhD, assistant professor of health services, policy and practice at Brown University [describes,] “For example, when a state restricts NPs from signing Do Not Resuscitate orders, that can serve as a barrier to advance care planning and could contribute to unnecessary hospitalizations at the end of life.” Editor's Note: We posted this JAMA Health Forum article on : Nurse Practitioner care, scope of practice, and end-of-life outcomes for nursing home residents with dementia.