• News New Blog Banner

  • Wasteful Care in Medicare 'Substantial and Widespread'

    Medicare beneficiaries "commonly" undergo tests and procedures that are of little benefit and could cost the system more than $8 billion a year, according to authors of a new study of 1.36 million beneficiaries. Though researchers say that the findings are "consistent with the notion that wasteful practices are pervasive in the US health care system," gauging the actual magnitude of the problem—and pinning down costs to Medicare—is not easy.

    The study, published in the May 13 issue of JAMA Internal Medicine (abstract only available for free), analyzes the use of "low value" services in cancer screening, diagnostic and preventive testing, preoperative testing, imaging, cardiovascular testing, and surgical procedures by way of 26 claims-based measures applied to Medicare claims from 2009. The services were chosen based on recommendations in the American Board of Internal Medicine (ABIM) Foundation's "Choosing Wisely" campaign, as well as other agencies. APTA is 1 of the first 3 nonphysician groups that will be participating in the Choosing Wisely campaign.

    The 26 services researchers selected for the study "provide little to no clinical benefit on average" and included procedures such as cervical cancer screening for women 65 and older, bone mineral testing at frequent intervals, preoperative stress testing, EEGs for headache, and PSA testing for men 75 years and older.

    Researchers used 2 screening approaches that had different "sensitivity" levels. They found that low-value procedures and tests occurred at the rate of about 80 services per 100 beneficiaries at the more sensitive analysis level, or about 21.9 million instances in 2009.The less sensitive analysis dropped use rate to about 33 services per 100 beneficiaries, with 9.1 million instances experienced by 25% of beneficiaries.

    Depending on the approach used, authors write, the prevalence of low-value services could amount to a per-beneficiary annual cost of either $310 or $71, which translates into Medicare costs of either $8.5 billion or $1.9 billion.

    "Even when applying narrower versions of our limited number of measures of overuse, we identified low-value care affecting one-quarter of Medicare beneficiaries," authors write. "Despite the limited number of services we examined, their frequency and correlations with one another suggest substantial and widespread wasteful care."

    One of the strongest findings of the research, according to the authors, is just how much more work needs to be done to develop a solid approach to analyzing low-value services. "Many quality measures have been developed to assess underuse but few to assess overuse," authors write.

    Research-related stories featured in News Now are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    New CMS Rules Target Consumers, Quality Reporting

    The US Centers for Medicare and Medicaid Services (CMS) has released a final rule (.pdf) on Exchange and Insurance Market Standards for 2015 and beyond that the agency claims is "aimed at giving consumers additional tools to evaluate their options and find plans that best meet their needs and budget." A summary of the rule is also available for download.

    The rule covers a range of issues including consumer notices, state restrictions on navigators, the Small Business Health Options Program (SHOP), and cost sharing. The changes, which will be implemented beginning in 2015, address the following areas:

    • The final regulation clarifies situations under which state restrictions of consumer assistance personnel (navigators, assisters, and certified application counselors) are preempted by federal law. It also imposes new federal restrictions on the consumer assistance personnel and authorizes civil money penalties on those who violate their federal obligations, breach the confidentiality of patient information, or assist in enrollment fraud. The final rule recognizes that states may regulate these personnel as long as the state regulations do not conflict with federal law or prevent the personnel from carrying out their responsibilities.
    • The new rule requires issuers to use standardized notices when renewing coverage or discontinuing products. The rule also addresses when insurance plans can modify coverage and when that modification constitutes termination of coverage.
    • For 2015, the maximum annual limit on cost sharing will be $6,600 for individual coverage and $13,200 for family coverage.
    • CMS reaffirms in the final rule its commitment to permit employee choice in the federal SHOP exchange beginning in 2015.
    • SHOP exchange rules will be modified to provide for an annual open enrollment period for all SHOPs aligned with the open enrollment period for the individual market.
    • The final rule provides additional guidance on the exchange quality reporting system. A number of state exchanges already report quality information on qualified health plans (QHPs), and the federal exchange intends to begin doing so in 2016 for the 2017 coverage year.
    • The US Department of Health and Human Services will be allowed to consult and share information concerning QHP insurers with other state and federal regulatory and enforcement agencies as necessary. The rule requires HHS to give insurers a 30-day notice setting out alleged violations and giving an opportunity to respond before the imposition of civil money penalties.

    PTNow Blog: Come and Get It

    In direct violation of the "what happens in Vegas" edict, the current PTNow blog is revisiting a popular giveaway from the 2014 Combined Sections Meeting (CSM): a handy "at a glance" reference on functional limitation reporting g-codes and severity modifiers.

    The postcard-sized version "was eagerly snapped up by nearly every attendee" who passed the PTNow booth in the exhibit hall, according to the blog. The new version can be easily downloaded to your smartphone or tablet.