The quick take-aways are:

• Whether state or federally run, or a mix, the all-important insurance exchanges will not be able to deny coverage and will not be able to charge certain types of patients (women, people with pre-existing conditions) more for coverage.  Remember – CMS just gave the states an additional four (4) weeks to consider to what extent they wish to have the federal government involved in running their individual state exchanges.
• One of the “quid pro quos” of the ACA – that as the number of covered lives is increased, other types of payments to hospitals for caring for the uninsured (e.g. the DSH payments) fade away over time – remains unchanged and is now on track.
• In the exchanges, insurers will have to cover 10 “basic” health care benefits – such as ER care, maternity care, prescriptions, and hospital stays.

It will be interesting to see in what direction states that have not yet made a choice as to their exchange model choose to go.

Clearly, the Recovery Auditors target “inpatient cases” becasue denials of inpatient status result in income for RACs. 

It is possible that a bright line test would result in a change of emphasis from review of the setting to review of the appropriatness of medical necessity.  Stay tuned – but comments are due September 4.

So, Dad, here’s to you!  I’ll keep snapping away to see what I can discover – I know you would want me to do just that.

We will see how this turns out, because the Commissioner of the Department of Insurance still has authority to regulate all insurance products sold in the state.

• Alignment of financing of health care must be aligned with health care reform.
• Most “health care laws” (you know, Stark, AKS, etc) are not related to the future financing of the health care system and the manner in which physicians and hospitals will be paid.
• Pathways to reform include (1) measurement and evidence-based medicine, (2) provider payment reform (i.e. from fee-for-service to bundled payments, value-based purchasing, et al, (3) benefit design, and (4) insurance choices.
• And for those of us who think about the future, patients will be “tracked” in order for the aggregagte of patient data to be used for the benefit of the whole.

Dr. Donald Burwick gave one of the keynote addresses.  Some of his points were:

• “The train has left the station” in the manner in which health care providers will be paid.
• Health care needs to be considered a human right.
• Like any other “system,” the health care system can (and must) be changed.  Specifically, the “new System” must improve: safety, effectiveness, patient centered-ness, timeliness, efficiency, and equity.
• Burwick cited “the moral test of government” as requiring that 100+ million people dependent upon governmental programs receive quality care.
• He cited some interesting examples of how a “system” can work.  For example, the “Nuka” program in Alaska and Denver Health.
• In addition, he pointed to the “Choosing Wisely” program as an example of providers themselves providing guidance.

Other speakers got into the nitty-gritty.  Here are some more technical points:

The OIG’s representative offered these thoughts:

• The Medicare exclusionary statute [Section 1128(b)(15)] should provide “obvious” guidance.  The OIG has become interested in exclusion not only for transgressions involving payments, but also seeks to exclude when there exists “poor quality of care,” almost like a public safety function.  In other words, poor quality + “relatively small financial transgression” could equal the remedy of exclusion from the Medicare program.
• OIG is looking for individual liability, not just “institutional liability.”
• If the OIG sees payment remedies of greater than $1 million, that is a “danger zone” and the government probably will seek exclusion.
• There is little to no tolerance for shoddy compliance programs.  Compliance must be part of operational responsibility.
• Boards of Trustees must take ownership of CIAs AND must make sure the entire organization understands the responsibilities inherent in a corporate integrity agreement.  Mitigation may occur when the organization can demonstrate how the individuals within the organization have themselves been involved with compliance.  The corollary to this is that actual and real compliance will allow the detection of non-compliance.

Antitrust:

• The FTC has a renewed sense of vigor in its campaign against “monopolization,” and seemingly has as its “mantra” the theme that if there is any threat to “price competition” in a particular market, they will look at integration with rigor.  Excuse the rhyme. 
• I asked Sara Razi of the FTC whether the FTC took into consideration the changing dynamics of health care reimbursement and the trends on obtaining better reimbursement through coordination and integration.  She responded that the FTC has heard from providers that their future reimbursement possibilities will result in lower prices.  The FTC remains unconvinced that such payment systems will lessen the threat of monopoly pricing.

Siging off here from Chicago. 

In a fairly recent Client Update, I highlighted the December 19, 2011 proposed rule implementing the Physician Payments Sunshine Act.  The Centers for Medicaid and Medicare Services (CMS) originally had stated that implementation would begin this year.  Well, physicians and manufacturers now are off the hook until at least 2013.  It turns out that for 2012 CMS will not be able to begin data collection required by the Act and any final rule that CMS adopts. 

In her May 3 letter to Senator Charles Grassley Marilyn Tavenner, CMS’ acting administrator, explained that “CMS does not believe it feasible to address all of the remaining issues” in time to finalize its rules on data collection for 2012.  For this year, disclosure of financial arrangements between physicians and manufacturers will not be required.   Tavenner assures us that a final rule will be produced later this year in time for the 2013 reporting season.