Dayton -Cincinnati area to be Medicare test ground

Pilot project aims to cut costs by training doctors to focus on prevention.

By Ben Sutherly, Staff Writer, Middletown Journal

Updated 10:06 AM Wednesday, April 18, 2012

DAYTON — The Dayton-Cincinnati area is one of seven regions nationwide chosen for a pilot project that will initially transform how doctors and other clinicians care for 330,750 U.S. Medicare and Medicaid enrollees. But it could have implications long-term for the nation’s entire health care system.

The project is part of a broader effort by the federal government to carve billions of dollars in costs out of the Medicare program in coming years to make it sustainable.

The cost of the project — called the Comprehensive Primary Care Initiative — wasn’t immediately available Tuesday. Modeled after private-sector approaches, it’s part of the federal health care overhaul and will transform how 75 of the region’s primary care practices are paid to care for patients. The project’s geographic reach will extend north to Springfield.

Participating practices will initially be paid an average of $20 per patient per month to better coordinate patient care.

Later, those practices will have the chance to share in a portion of any Medicare savings.

“This is probably the biggest change in the delivery of primary care since primary care was defined as a specialty,” said Evan Steffens, director of clinical and quality services for Premier HealthNet and Premier Health Specialists, which are part of Premier Health Partners.

“Prior to now, the practices managed the patient that presented at their door or called the office for a visit,” Steffens said. “In this (new) system, the practice reaches out to their patient community and manages everybody, whether they contact the office or not. It’s a very different way of looking at care.”

Through electronic health records, primary care practices taking part in the pilot program will focus not just on treating patients when they are ill, but will focus more on keeping them healthy, manage chronic health conditions such as diabetes, and head off the need for more expensive surgeries and other procedures. The practices also will work to intensively manage care for high-need patients, ensure access to care beyond regular business hours, provide more preventive care, and encourage patients to be more engaged in their care.

Ohio itself will spend $1 million in the next two years to train 50 practices to become “patient-centered medical homes,” which like the federal pilot program involves greater coordination of the care a patient receives. Dr. Ted Wymyslo, director of the Ohio Department of Health, advocated for the approach for years as a doctor practicing in Dayton. He said he will encourage southwest Ohio practices selected for the state’s pilot program to also apply for the federal pilot program.

As of March 1, Ohio had 118 practices that had been certified as patient-centered medical homes by the National Committee for Quality Assurance. The state and federal pilot programs will drive that number higher. “It’s going to drive huge practice change,” Wymyslo said of the Medicare pilot program. “It’s a movement. … My prediction is it won’t be long until you see this migrating to all four corners of the state.”

Southwest Ohio’s participation in the four-year federal program is significant, Wymyslo said. It demonstrates insurance companies are willing to embrace — and pay for — the new care concept.

Practices that make “meaningful use” of electronic health records — and that have a majority of patients covered by health plans willing to pay enhanced reimbursements — will likely have a leg up in vying to become one of the region’s 75 pilot practices in the Medicare pilot, Premier HealthNet’s Steffens said. Medicare will also likely want the 75 practices in southwest Ohio to be a diverse group, she said.

Jason Koma, spokesman for the Ohio State Medical Association, said physicians statewide are supportive of the patient-centered concept. “We’ve seen what happens when you pay just (based) on the volume of service. Ultimately, that model is not sustainable.”

Other regions taking part in the program are the Tulsa region of Oklahoma and Hudson Valley region of New York, as well as the entire states of Arkansas, Colorado, New Jersey and Oregon.


Competition cuts down Medicare fraud

AP NewsBreak: Competition cuts down Medicare fraud

By RICARDO ALONSO-ZALDIVAR, Associated Press – 2 minutes ago 

WASHINGTON (AP) — A yearlong experiment with competitive bidding for power wheelchairs, diabetic supplies and other personal medical equipment produced $200 million in savings for Medicare, and government officials said Wednesday they are expanding the pilot program in search of even greater dividends.

The nine-city crackdown targeting waste and fraud has drawn a strong protest from the medical supply industry, which is warning of shortages for people receiving Medicare benefits and economic hardship for small suppliers. But the shift to competitive bidding has led to few complaints from those in Medicare, according to a new government report.

The report found only 151 complaints from a total population of 2.3 million Medicare recipients in the nine metropolitan areas, including Miami, Cincinnati and Riverside, Calif.

As a result, the program is expanding to a total of 100 cities next year, along with a national mail order program for diabetes supplies such as blood sugar testing kits. Eventually the whole country will participate.

Medicare traditionally has struggled to manage medical equipment costs. Officials say the program often paid more than private insurers for comparable equipment and was vulnerable to fraud by unscrupulous suppliers ordering expensive but unneeded products for unwitting beneficiaries.

By shifting to competitive bidding with a limited number of approved suppliers in each area, Medicare will save nearly $26 billion from 2013-2022, the government estimates, and reduce costs for seniors without cutting benefits.

“What we see is that costs are lower and there is no impact on the health status of our beneficiaries,” said Jonathan Blum, deputy administrator for Medicare. “This gives us very strong confidence that we can expand the program. To us, this is a clear success.”

The home-care supply industry sharply questioned that conclusion.

“With respect to the number of complaints (the report’s) information is downright laughable,” said Walt Gorski, a senior lobbyist for the American Association for Homecare. “It defies logic.” The group represents suppliers of home health equipment, ranging from oxygen to hospital beds.

The industry says hundreds of economists at academic institutions around the country have concluded that Medicare’s competitive bidding model is flawed and could lead to shortages or force beneficiaries to use less desirable cut-rate equipment.

In its report, Medicare said it closely monitored the health of beneficiaries likely to use home equipment in the nine areas involved with the competitive bidding experiment. It then compared the results to data for beneficiaries in other similar areas where competitive bidding has not been instituted yet. Using yardsticks such as emergency room visits and nursing home admissions, it found no significant differences.

“We have not seen any change in health status or access to services once the program went into place,” said Blum.

The report said the Medicare consumer hotline received 127,466 calls from beneficiaries about the competitive bidding program during 2011, less than 1 percent of the total volume of calls received. Most involved routine matters, such as locating a supplier.

Medicare defined complaints as dissatisfaction that could not be resolved by a call center operator. It registered 151 complaints for the year, the vast majority in the first six months of the program. Only six complaints were logged in the last three months of the year.

Medicare also called a sample of beneficiaries in areas where there was a sharp drop the quantities of supplies ordered for diabetes testing and for sleep apnea machines. The report said “in virtually every case” the beneficiary reported having more than enough supplies on hand, often several months’ worth.

“This would suggest that beneficiaries received excessive replacement supplies before they became medically necessary,” according to the report

The nine metropolitan areas involved in the experiment were Charlotte-Gastonia-Concord (North Carolina and South Carolina); Cincinnati-Middletown (Ohio, Kentucky and Indiana); Cleveland-Elyria-Mentor (Ohio); Dallas-Fort Worth-Arlington (Texas); Kansas City (Missouri and Kansas); Miami-Fort Lauderdale-Pompano Beach and Orlando (Florida);, Pittsburgh; and Riverside-San Bernadino-Ontario (Calif.).

Nine categories of medical equipment are included in the program: oxygen supplies, standard power wheelchairs, complex power wheelchairs, mail-order diabetic supplies, tube-feeding supplies and equipment, sleep apnea machines and equipment, hospital beds, walkers, and certain types of mattresses.

The major components of the $200 million saved last year were $59 million from oxygen supplies and equipment, $51 million from mail-order diabetic supplies and nearly $40 million from power wheelchairs and similar devices.