TGIF

It’s the FEHBlog’s first merry month of May post.

The Centers for Medicare and Medicaid Services informally has disclosed the October 1, 2015, will be the ICD-10 coding set compliance date according to ihealthbeat.  CMS made this announcement in the preamble to the proposed Medicare inpatient hospital pricing rule for FY 2015. According to the CMS press release on that rule:

CMS projects that the payment rate update to general acute care hospitals will be 1.3 percent in FY 2015

Hospital Readmissions Reduction Program.  The maximum reduction in payments under the Hospital Readmissions Reduction program will increase from 2 to 3 percent as required by law.  For FY 2015, CMS proposes to assess hospitals’ readmissions penalties using five readmissions measures endorsed by the National Quality Forum (NQF). Already, CMS estimates that hospital readmissions in Medicare declined by a total of 150,000 from January 2012 through December 2013.

Hospital-Acquired Condition Reduction Program.  CMS proposes to implement the Affordable Care Act’s Hospital Acquired Condition (HAC) Reduction Program.  Beginning in FY 2015, hospitals scoring in the top quartile for the rate of HACs (i.e. those with the poorest performance) will have their Medicare inpatient payments reduced by one percent.  This new program builds on the progress in this area achieved through the existing HAC program, which is currently saving approximately $25 million annually by reducing Medicare payments when certain conditions that are reasonably preventable are acquired in the hospital.

The rule also describes how hospitals can comply with the Affordable Care Act’s requirements to disclose charges for their services online or in response to a request, supporting price transparency for patients and the public.

Today the ACA regulators issued ACA FAQ XIX. The FAQs discuss among other things the Labor Department’s new COBRA notices which highlight the potential benefits of selecting Marketplace over COBRA coverage, and application of the out of pocket maximum rule to reference pricing (the FEHBlog loves the reference pricing concept). The FAQ also announces that the Summary of Benefits and Coverage (and related instructions) and the Uniform Glossary will not be changed this year. 
Oddly in the FEHBlog’s view, Medicare is not subject to the preventive services coverage rules that apply to plans that must comply with the ACA.  The ACA governed plans including FEHB plans must defer to the U.S. Preventive Services Task Force recommendations (grades A and B). In 2013 the USPSTF gave a grade B recommendation to 

annual screening for lung cancer with low-dose computed tomography in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once the individual has not smoked for 15 years or develops a health problem that significantly limits life expectancy or the ability or willingness to have curative lung surgery.

This recommendation governs FEHBP preventive cares services beginning next year.  Modern Healthcare reports that

Some experts are predicting that the CMS will go along with Wednesday’s controversial decision by an advisory panel not to recommend Medicare coverage of annual CT scans to detect lung cancer in heavy smokers. The nine-member Medicare Evidence Development and Coverage Advisory Committee voted Wednesday that there is not enough research evidence to justify covering the scans. 

This means that if CMS does stand by this recommendation, FEHB plans next year must cover the test which costs $300 to $400 for members with primary Medicare coverage as well as younger members. That’s illogical.

Speaking of nonsequiturs, the FEHBlog took note of this Health Day story concluding that health obesity may be a myth:

Can someone be obese and healthy? A new study and several experts say no. An obese person who has normal blood pressure, normal cholesterol and normal blood sugar levels is still at risk for heart disease, Korean researchers report in the April 30 online edition of the Journal of the American College of Cardiology.

Dr. David Katz, director of the Yale University Prevention Research Center, said these findings are not surprising and expects that the same results would be found among obese Americans.”There has long been debate about the relative importance to health of fitness versus fatness. The argument has been made that if one is fit, fatness may not be a significant health concern,” he said. While fat and fit is better than fat and unfit, this study adds to a growing body of evidence that challenges that assertion. “Excess body fat can increase inflammation, one of the key factors contributing to heart disease, and other chronic diseases as well,” Katz said.

This study certainly supports OPM’s decision to encourage FEHB plans to expand coverage of bariatric surgery for obese FEHB plan members. 

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