After three years of providing penalties and bonuses to hospitals treating Medicare patients through the Affordable Care Act’s (ACA) Hospital Value-Based Purchasing (HVBP) Program, the Government Accountability Office (GAO) has found that the amount of a hospital’s payment adjustment is well-aligned with the hospital’s net income—hospitals with a higher net income received the largest bonuses. This finding is not all that surprising (with one exception: hospitals in the lowest net income range in 2013 had the second-highest payment adjustment in 2015). While potentially a chicken-and-egg situation, hospitals with low or negative net income are not likely to have the available resources necessary to make needed improvements. When a hospital is penalized for its poor performance, the situation worsens. In all three years, average payment adjustments for safety net hospitals were negative. Interestingly, the most commonly cited challenge to improving quality was health information technology (IT), which every hospital is being required to utilize in the hopes that such technology will catalyze quality improvements. Additionally, the GAO found “no apparent shift... in hospitals’ performance on the quality measures included in the HVBP program”.
Improper drug use, and the negative health effects of such, has been of increasing concern over the past several years. In 2012, of the approximately 36 million young adults in the U.S. aged 18-25 in the U.S., more than one third reported binge alcohol use and one fifth reported illicit drug use in the past month. The total number of emergency room (ER) visits caused by problems or complications from using drugs (both legal and illegal, prescribed or otherwise) reached nearly 5.1 million in 2011, an increase of 88 percent from 2004. ER visits following use of pain relievers—responsible for 23 percent of all ER visits due to drug use in 2011—increased 126 percent, with oxycodone and hydrocodone accounting for 46 percent of that increase. ER visits for non-alcohol illicit drug use only increased 19 percent. ER visits for users of antidepressants increased 55 percent, while ER visits due to use of anti-anxiety medicines increased 126 percent. At the average charge for an ER visit in 2013 of $1,233, the cost of these visits would total nearly $6.3 billion.
Between January 2011 and May 2015, less than $10 million in Medicare Part D improper payments had been recovered by the Centers for Medicare and Medicaid Services—less than 0.14 percent of improper payments made during this time period. Over the last decade, approximately 4 percent of all federal government payments each year were improper, but 9.5 percent of all Medicare and Medicaid payments last year were improper. Medicare and Medicaid have accounted for half of all improper payments by the federal government over the last 11 years, and since 2009, these two programs have been responsible for at least 55 percent of all improper payments each year. In 2014, Medicare Fee–for-Service (Parts A & B) accounted for 37 percent of all improper payments by the federal government; Medicare Advantage (Part C): 10 percent; Medicare Part D: 2 percent; and Medicaid: 14 percent.
Recently, the Centers for Medicare and Medicaid Services (CMS) released payment data for the 100 most commonly used DRGs by state. The data reveals a lot of disparity between the average DRG costs and also shows the considerable differences in Medicare payments to physicians from state to state.
The Centers for Medicare and Medicaid Services (CMS) recently released payment data for the 100 most commonly billed discharges by Diagnosis Related Group (DRG) at more than 3,000 hospitals using the Inpatient Prospective Payment System (IPPS) in 2013. These payments represent over 7 million discharges, or 60 percent of the total IPPS discharges billed to Medicare that year. The following chart shows the top 10 costliest DRGs to the Medicare system as a whole, counting payments by both the government (and/or supplemental private insurance) and beneficiaries (including copayments and deductibles). These 10 DRGs were responsible for nearly 1.7 million discharges with total payments per discharge averaging nearly $23,000 for a total cost of more than $26 billion. As illustrated, much of the cost is driven by the number of discharges—particularly for major joint replacement (DRG 470) and septicemia (DRG 871)—rather than the cost of the services. Percutaneous cardiovascular procedure (DRG 247) was the only DRG in this top 10 that was not also in the top 10 for number of discharges or average total payments per discharge.
According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 43.8 million adults suffer from a mental illness which represents nearly 20 percent of the U.S. population
The Affordable Care Act (ACA) allowed the creation of non-profit consumer operated and oriented plans (co-ops) which would be allowed to sell health insurance to a state’s residents either on or off the newly-created Exchanges. These co-ops were eligible for both start-up and solvency loans, and the Centers for Medicare and Medicaid Services (CMS) awarded $2.4 billion in loans to 23 new co-ops. One criteria for receiving such loans was a high probability of becoming financially viable. While most of the co-ops were expected to lose money in the first year (as most new businesses do), the Health and Human Services Office of the Inspector General found 19 of the 23 co-ops exceeded their projected losses; 10 co-ops lost more than $2,000 per enrollee. Projections show 11 co-ops are expected to still be losing money by the end of 2015. Maine’s co-op, the only one not to lose money in 2014, had the lowest priced plans (despite only drawing down 32 percent of the loans they were awarded and enrolling more than 2.5 times as many individuals as anticipated) and attracted 80 percent of the state’s marketplace consumers. The chart below shows the net loss per enrollee for each co-op by state, which averaged $2,712. The total loss was $539 million.
In all, 48 states (including DC) requested significant increases in either the individual or the small group market, while 34 states had at least one individual market plan that requested significant increases.
In 2014, national spending on health care products and services totaled $3.1 trillion, or $9,695 per person, and accounted for 17.4 percent of our gross domestic product (GDP). Medicaid enrollment grew by 12.9 percent in 2014, while spending on the program grew by 12 percent (federal and state spending grew 17.7 percent and 3.4 percent, respectively) totaling $503.3 billion and accounting for 16.3 percent of national health expenditures (NHE). Average spending per beneficiary in Medicaid was 1.4 times greater than spending on individuals with private health insurance. The chart below provides insight into where that money is going: a large share of the nation’s spending on nursing and retirement care, home health care, and other residential and community-based services are paid for by Medicaid.
As the nation marks the 50th Anniversary of the creation of Medicare and Medicaid, it is important to both look back at how the programs have evolved, as well as forward at what’s to come. But be careful—the trajectory may alarm you. Between 2010 and 2023, total expenditures on Medicare and Medicaid will more than double to nearly $2 trillion annually, while enrollment during that same period is only expected to increase by 45 percent. Spending on Medicare did not surpass $500 billion until 2009, 44 years after the program began; but it will only take 13 years beyond that to increase by the same amount. In the 10 years between 2014 and 2023, average annual enrollment growth in both Medicare and Medicaid will be approximately 3 percent, while average annual growth in expenditures will be more than double the rate of enrollment for both programs—6.2 percent for Medicaid and 7 percent for Medicare.