Politico reported on a pilot program in ObamaCare. In an experiment under the Affordable Care Act, the Pioneer Accountable Care Organization program, were all able to improve patient care. Some were even able to lower Medicare costs.  The program’s results are similar to results found in the private sector, says Mark McClellan, former CMS administrator. The program is trying to reduce health care costs by increasing the health of patients through quality of care and reducing hospitalizations. In doing so, the results won’t spell immediate success for most organizations. McClellan advises that in a year, year and a half, or two years time, we will begin to see serious improvements in the health of patients, and a direct link to lowered Medicare costs. The Pioneer ACO will continue in the experiment, although some of the providers have left the program.

A few weeks ago, we posted a blog about the connection between doctors and prescription sales. In that article, financial data was used to show that doctors who worked with a pharmaceutical company, giving presentations and speeches, were more likely to prescribe a drug that the company had marketed.

In a similar tale of big pharma influence, one St. Louis company has been entangled in a lawsuit under the False Claims Act. John Prieve, the whistleblower who brought forth the suit, worked at Mallinckrodt LLC. In his suit, he claims that Mallinckrodt defrauded the government because they used financial incentives to increase the number of doctor prescriptions their drug got. In doing so, many of the prescriptions were paid by Medicare and Medicaid, essentially placing the added cost on the government. The suit alleges that the company ‘targeted doctors’ who prescribed similar drugs in an attempt to increase sales of the less effective and more expensive antidepressants and sleep aids that Mallinckrodt made. The company is settling the suit for $3.5 million.

McKnight’s reported thatTennessee-based nursing home operator Grace Healthcare LLC will pay the federal government more than $2.7 million, settling charges that Grace violated the False Claims Act by billing Medicare for unnecessary rehabilitation therapy.   A whistleblower said 10 Grace-operated skilled nursing facilities billed for unnecessary and unreasonable physical, occupational and speech therapy to meet the corporation’s reimbursement goals from 2007 to 2011.

The government proved that Grace’s billing was an example of “waste and abuse” driven by “financial considerations,” said U.S. Attorney for the Eastern District of Tennessee Bill Killian.  Grace will enter into a Corporate Integrity Agreement regarding its therapy services as part of the settlement. The former Grace employee received $405,000 under the settlement agreement.


The L.A. Times reported that health care consumers saved nearly $1.5 billion in 2011 as a result of the Affordable Care Act (Obamacare) that limit what insurance companies can spend on expenses unrelated to medical care, including profit, a new analysis by the New York-based Commonwealth Fund shows.  Much of those savings — an estimated $1.1 billion — came in rebates to consumers required because insurers had exceeded the required limits. The study also suggests that the Affordable Care Act forced insurers to become more efficient by limiting their administrative expenses, a key goal of the 2010 law.

In some cases, insurers passed savings on to consumers in the form of lower premiums and higher spending on medical care, the researchers found.   Administrative costs in the individual market dropped in 39 states, with major improvements in South Carolina.  Insurers in 37 states spent relatively more of their customers’ premiums on medical care, with big gains in South Carolina.

Stepping up regulation of health insurance companies has been a top priority for consumer advocates, who have complained for years that insurers routinely increase premiums to pad profits and executive salaries rather than pay for medical care. The healthcare law attempts to address this by requiring insurers to spend at least 80 cents of every dollar they collect in premiums on medical care, rather than on administrative expenses.  Insurers selling to employers must meet an even tougher standard, spending at least 85 cents of every dollar on medical care.


The Washington Post reported that the Justice Department’s civil division recovered a record $5 billion in the past fiscal year from companies that defrauded taxpayers, with much of the abuse occurring in the health-care industries.  The amount of money recovered in 2012 is up from $3.2 billion last year, and two-thirds of it was secured through the act’s whistleblower provisions.


The Washington Post published an interesting article that sheds light on Mitt Romney’s plan to help those with preexisting conditions get health insurance. Romney claimed during the past debate, “I do have a plan that deals with people with pre-existing conditions.” However, he is unable to articulate how it will help anyone other than those that have maintained continuous insurance coverage and it is still unclear how the 49 million uninsured individuals will get coverage.

As the article explains, the plan that Romney has been stressing will only help those with pre-existing conditions that have maintained continuous health insurance coverage. This means that anyone who may have had a break in coverage due to losing their job or for any other unforeseeable reason will not be helped at all by Romney’s plan.

After all of Romney’s talk about making it easier for those with pre-existing conditions to get coverage, in actuality only a small fraction of those with problem medical conditions will be helped, leaving a far greater number of people out of luck.

This plan is in stark contrast to President Obama’s health care law that allows those with preexisting conditions the same comprehensive coverage, at the same rates that every other citizen pays.  As the law says, an insurance company “may not impose any pre-existing condition exclusion.” Karen Pollitz, an insurance market expert, explains that Romney’s plan is much more unlikely to provide a solution than the president’s Affordable Care Act. Pollitz explains, “The ACA just says insurance companies can’t discriminate against you, period. If you’ve been uninsured, you can come into this market on Jan. 1, 2014, no questions asked.”


We are attaching talking points that will be useful when discussing both rehabilitation services and habilitation services as essential services under State Insurance Exchange Programs required to be created pursuant to the Affordable Care Act.  Persons suffering from a brain injury should receive adequate medical and rehabilitation services under the Affordable Care Act.  

The outcomes of rehabilitation and habilitation services and devices are consistent with core
American values because they enable people to:
• Maximize independence in the least restrictive environment;
• Live active and productive lifestyles that embrace family, work, education, and community; and
• Avert medical complications and minimize hospital readmissions.

These outcomes are important to individuals, families, and society. By promoting these outcomes, overall health care costs can be reduced, and thus provide significant value to American taxpayers.


The Eldercare Workforce Alliance (EWA) is pleased to see the inclusion of eldercare workforce provisions within a bill to reauthorize the Older Americans Act, introduced by Senator Bernie Sanders, chairman of the Senate Subcommittee on Primary Health and Aging, and fourteen other cosponsors.


OAA reauthorization offers an important opportunity to modernize the aging services network and its programs in order to build an eldercare workforce with the skills and training to meet the “whole person” needs of older adults for health care and long-term services and supports (LTSS).


The Alliance is especially pleased by the inclusion of efforts to address the shortage of workers specially trained to care for older adults. Provisions within the bill that call on cross-agency communication to identify and address workforce shortages are crucial to meeting the needs of an aging America. Furthermore, the bill codifies into law the eligibility of professionals trained in geriatrics and gerontology within the National Health Service Corps. This provision is based on language from the Caring for an Aging America (CAA), a bipartisan bill introduced by Senators Barbara Boxer, Susan Collins, Herb Kohl, and Bernie Sanders. The inclusion of the CAA within OAA reauthorization capitalizes on an essential opportunity to strengthen the eldercare workforce. Without a well-trained workforce, the delivery of vital services provided through the Older Americans Act will suffer.


EWA also supports efforts to invest in better and more meaningful supports for family caregivers and direct-care workers. EWA strongly supports the information and services provided by the National Family Caregiver Support Program, such as the individual counseling, caregiver training and respite which are so essential to family members and other informal caregivers. We support strengthening services for family and informal caregivers by authorizing and providing grants to states to conduct assessments of family or informal caregivers’ own needs for services and supports. We support the testing of new innovative models of person and family-centered care that encourage well-coordinated, interdisciplinary team care, in which each team member works to the full extent of his or her knowledge, training, and skills. Finally, we support models which provide direct-care workers with additional training and utilize them in new roles to improve efficiency and quality of care for frail elders.


Senior Housing News had an article about Medicare’s reimbursement being linked to quality care.  “Medicare is planning on eventually introducing a payment system for skilled nursing facilities that’s based on the quality of care being given rather than on costs and resources, but first it needs to figure out a system for doing so by analyzing results from its three-year “Nursing Home Value-Based Purchasing Demonstration” project, which ended on July 1.”

The national incentive pay program for nursing homes to provide superior quality in order to receive better payments is an initiative of the Affordable Care Act, but it will be several years in coming.  See report to Congress on the demonstration project.

Health policy experts remain optimistic that the current system can be transformed into a “higher performing, value-driven” healthcare system.  The Centers for Medicare and Medicaid Services (CMS) views the implementation of this sort of quality-based payment program as an important step in revamping how Medicare pays for healthcare services, says HHS, aiming to hold providers accountable for the quality of care they provide to Medicare beneficiaries, promote more effective, efficient and high quality care processes, and address the variation in quality across care settings.

The plan for this program will link payment to performance to “improve value for Medicare beneficiaries and other residents residing in SNFs by promoting the development and use of robust quality measures to allow patients and providers to assess the quality of skilled and non-skilled care furnished in SNFs,” says the report. “[T]he emphasis on Medicare beneficiares’ functional status can help prepare them for discharge to a less intensive non-institutional setting.”