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Cancer Risk Falls with Higher Levels of Vitamin D

In the journal PLOS One, researchers from the University of California-San Diego (UCSD) School of Medicine report how they analyzed the link between vitamin D and cancer to determine what blood level of vitamin D was required to effectively reduce cancer risk. The study included all invasive cancers, excluding skin cancer.

One of the authors, Cedric Garland, adjunct professor in the UCSD School of Medicine Department of Family Medicine and Public Health, says their study is the first to put numbers on this relationship, as he explains:

“We have quantitated the ability of adequate amounts of vitamin D to prevent all types of invasive cancer combined, which had been terra incognita until publication of this paper.”

Vitamin D, which is produced by the body through exposure to sunshine, helps the body control calcium and phosphate levels. It was Prof. Garland and his late brother Frank who first linked low vitamin D with cancer in the 1980s. They found people who lived at higher latitudes and thus had less access to sunlight had lower levels of vitamin D and were more likely to develop bowel cancer.

Since then, further studies by the Garland brothers and others have found links between low vitamin D and other cancers, including cancers of the breast, lung and bladder.

Much debate about recommended level of vitamin D

The only accurate way to measure vitamin D in the body is to measure the level of 25-hydroxyvitamin D in the blood. The kidneys convert 25-hydroxyvitamin D into the active form that helps control calcium and phosphate levels.

There has been much debate in recent years about what the recommended blood levels of vitamin D should be. In 2010, the Institute of Medicine (IOM) recommended a target of 20 ng/ml for bone health, which could be met in most healthy adults (aged 19-70), with the equivalent of 600 IU of vitamin D each day. Since then, other groups have argued that the target level should be higher, at 50 ng/ml or more.

In the new study, Prof. Garland and colleagues wanted to find out what blood level of vitamin D effectively reduces cancer risk.

They took an approach that is not normally used. They used the results from two different types of study: one a clinical trial of 1,169 women and the other a prospective study of 1,135 women. For some of their analysis, they kept the two data sets separate and compared them, and in another part, they pooled the data to create a larger sample.

Vitamin D level of 40 ng/ml or higher tied to 67% lower cancer risk

The median blood level of 25-hydroxyvitamin D in the participants in the clinical trial was 30 ng/ml, and in the participants in the prospective study, it was 48 ng/ml.

The researchers found that the rate of cancer incidence in the clinical study group (that had the lower median vitamin D level) was higher than in the prospective study group. The figures were 1,020 cases per 100,000 person-years and 722 per 100,000 person-years, respectively.

They also found that cancer rates went down as 25-hydroxyvitamin D levels rose; women whose vitamin D level was 40 ng/ml or higher had a 67% lower risk of developing cancer than women whose vitamin D level was 20 ng/ml or lower.

The researchers did not say what the optimum intake level of vitamin D should be – or how it should be generated, whether by greater exposure to sunlight, dietary changes or supplements.

Prof. Garland says their findings simply show that it is possible to see reduced cancer risk when blood levels of vitamin D reach 40 ng/ml, and that higher than this, the risk drops even further. He and his colleagues conclude:

Primary prevention of cancer, rather than expanding early detection or improving treatment, will be essential to reversing the current upward trend of cancer incidence worldwide. This analysis suggests that improving vitamin D status is a key prevention tool.”

CMS Finalizes its Quality Measure Development Plan

On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals and 150 organizations.

Thank you for your comments, which we carefully reviewed and considered as we revised and finalized the plan. I am happy to announce that we posted the final Quality Measure Development Plan on the CMS website today.

CMS aims to drive improvement in our national health care system through the use of quality measures and periodic assessment of the impact of such measurement. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established payment incentives for physicians and other clinicians based on quality, rather than quantity, of care. We recently released the proposed regulation to implement these payment incentives, and more information is available here.

The Quality Measure Development Plan is an essential aspect of this transition, which will provide the foundation for building and implementing a measure portfolio to support the quality payment programs under MACRA.

Highlights from the comments we received on the draft plan include:

  • Many commenters expressed support for the strategic approach of the Quality Measure Development Plan.
  • Responses favored CMS’ intent to engage clinicians, medical societies, and other stakeholders more broadly in measure identification, selection, and development processes for MIPS and APMs.
  • Professional associations representing diverse clinical practice areas identified current measurement gaps and proposed priorities for measure development that are directly applicable to their specialties.
  • Consumer advocates urged CMS to partner with patients, families, and caregivers and recommended a model for engaging them in measure development.
  • Many commenters approved of the approach envisioned by the National Testing Collaborative and the National Quality Forum (NQF) Incubator to promote early engagement of stakeholders in measure development and testing.
  • Both organizations and individuals contributed insights into the integral roles of their clinical professions or practices in the U.S. health care delivery system.

Taking these comments and suggestions into consideration, CMS finalized the Quality Measure Development Plan to include:

  • Identification of known measurement and performance gaps and prioritization of approaches to close those gaps by developing, adopting, and refining quality measures, including measures in each of the six quality domains:
    • Clinical care
    • Safety
    • Care coordination
    • Patient and caregiver experience
    • Population health and prevention
    • Affordable care
  • CMS actions to promote and improve alignment of measures, including the Core Quality Measures Collaborative, a work group convened by America’s Health Insurance Plans (AHIP). On February 16, 2016, CMS and the Collaborative announced the selection of seven core measure sets that will support multi-payer and cross-setting quality improvement and reporting across our nation’s health care systems.
  • Partnering with frontline clinicians and professional societies as a key consideration to reduce the administrative burden of quality measurement and ensure its relevance to clinical practices.
  • Partnering with patients and caregivers as a key consideration for having the voice of the patient, family, and/or caregiver incorporated throughout measure development.
  • Increased focus and coordination with federal agencies and other stakeholders to lessen duplication of effort and promote person-centered health care.
The MACRA law provides the opportunity to further progress the Medicare program and our national health care system toward paying for value rather than volume.  However, the successful implementation of the Quality Payment Program established by MACRA requires a partnership with patients, their families, frontline clinicians, and professional organizations to develop measures that are meaningful, applicable, and useful across payers and health care settings. We thank all who contributed comments and dialogue to the draft CMS Quality Measure Development Plan, and we look forward to partnering with you on these exciting efforts related to our quality payment programs.

How To Get Rid Of Bed Bugs

Bed bugs, known scientifically as Cimex lectularius (Cimicidae) are small wingless insects that feed by hematophagy – exclusively on the blood of warm blooded-animals. As we are warm-blooded animals, we are ideal hosts for them.

Over millions of years, bed bugs have evolved as nest parasites – inhabiting the nests of birds and the roosts of bats. Some of them have learnt to adapt to the human environment and live in our nests, i.e. our homes, and more specifically, our beds. Newborns, called hatchlings or nymphs, are tiny, about the size of a poppy seed, while adults grow to about ¼ of an inch long. Their shape is oval and flattened. Both nymphs, eggs and adults are visible to the naked eye.

They are called bed bugs because of their preferred habitat in human homes: sofas, bed mattresses and other soft furnishings.

Bed bugs are seen as a growing problem within all types of dwellings, including private homes, dormitories, cruise ships, army barracks, and shelters.

Bed bugs breed successfully in various environments and circumstances. On 12th December, 2011, experts at SRI International reported that bed bugs can inbreed and still produce healthy offspring.

When seen close up they may have a white, light tan to a deep brown or burnt orange color. Just after molting, most of them are plain white. When they have had their feed a dark red or black blob may be observed within their body. They will instinctively seek shelter in dark cracks and crevices when disturbed.

Spotting signs of bed bugs

The biggest sign of bed bugs is people complaining of bites that occurred while they were asleep. If this happens, you should examine the bedrooms for bed bugs and signs of bed bug activity. Look carefully into the creases in the bed linen, and seams and tufts of mattresses and box springs for bugs or eggs. The eggs will look like tiny pale poppy seeds.

Signs of bed bug activity may exist beneath loose areas of wallpaper near beds, in the corner of desks and dressers, in the laundry, and in drawers.

Look out for dark brown or reddish fecal spots (bed bug droppings, excrement). If the area is very infested you may sense a coriander-like odor. The excrement is a liquid that looks either light brown or black that can either bead up or be absorbed by the material around it.

Dogs can be trained to sniff out live bed bugs or past infestations. A dog’s sense of smell is so acute that it can pick up the scent of a single bed bug

For more information click here.

Missouri Law Creates New ‘Assistant Physician’ Designation

Signed last week by Governor Jay Nixon, the law creates the new position of “assistant physician.”

A controversial new law in Missouri will allow medical school graduates who haven’t yet passed their final credentialing exam to treat patients in under-served primary care settings. The law has encountered strong opposition from organized medicine.

Signed last week by Governor Jay Nixon, the law creates the new position of “assistant physician.” These doctors would be supervised on site by a collaborative physician for 30 days. After that, they could treat patients without direct supervision in settings 50 miles away and will be able to prescribe Schedule III, IV, and V drugs.

The assistant physician can provide only primary care services and only in medically under-served rural or urban areas of the state or in any pilot project areas, the law states. An assistant physician is defined as any medical school graduate who has passed the prescribed medical examinations and who has not entered into postgraduate residency training prescribed by rule of the State Board of Registration for the Healing Arts.

The Missouri State Medical Association (MSMA) helped draft the legislation and said it is necessary because a physician shortage especially in under-served areas has limited access to care. Missouri last year was listed by the federal government as 1 of the 10 most medically under-served states in the nation.

“This is a decent solution,” Jeffrey Howell, the MSMA’s general counsel and government relations director, told Medscape Medical News. “Patients in these areas aren’t getting any care now. Our attitude is that some care is better than no care. We hope this law will be a trailblazer for other states.”

Howell said the assistant physicians have graduated medical school and passed the first 2 sections of the licensing exam. They must be approved by the Missouri Board of Healing Arts and must find a physician willing to collaborate with them. It will likely take the board a year to promulgate regulations for assistant physicians.

medical school graduates

“Flawed Assumption”

Opposition from organized medicine was swift. Thomas Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education, said the possibility of harm is striking.

“These are physicians with only rudimentary experience,” he told Medscape Medical News. “In Missouri, without direct supervision, they’d be able to manage patients with complex diabetes, congestive heart failure, arrhythmias, and malignancies. This doesn’t make sense.

“Physicians in the United States are not trained to enter practice upon graduation from medical school,” Dr. Nasca said. “They don’t have the skill sets required for independent practice. It’s a flawed assumption to suggest that novices are prepared to provide clinical care on their own in a rural area where any medical condition could present itself. This isn’t an emotional response. It’s a data driven response to a very bad idea.”

Despite recognizing the need to serve challenged areas, he doesn’t see this as the appropriate remedy. “I don’t underestimate the challenges we face in delivering care to rural populations and the urban poor. But to provide inadequate care is no solution. There is a dramatic difference between a medical school graduate and a doctor trained in a residency program. Why go back to the 1940s when doctors just out of medical school provided care without supervision? The idea that primary care is somehow simple is ludicrous,” Dr. Nasca said.

Paving The Way For Virus-Like Nanodevices That Diagnose Disease And Make Drugs

Mimicking viruses to target specific cells

Nanotechnology is a relatively new, but rapidly expanding field, where tiny devices and molecular-scale tools offer exciting possibilities for manipulating cells and their components. Now researchers, copying the tactics used by viruses to evade the immune system, have created the first nanodevices that survive the body’s immune defenses. The achievement supplies a missing piece to the puzzle of how to use nanodevices at the cellular level.

Scientists at Harvard’s Wyss Institute for Biologically Inspired Engineering in Boston, MA, say their DNA nanodevice has successfully completed its first pilot mission.

Writing in ACS Nano, they conclude the accomplishment provides “a platform for the engineering of sophisticated, translation-ready DNA nanodevices.”

Such “smart DNA nanorobots” could use logic to diagnose diseases like cancer earlier than current approaches can. They could also target drugs directly to chosen tumors, or even manufacture them on the spot.

Mimicking viruses to target specific cells
Senior author William Shih, an associate professor of Biological Chemistry and Molecular Pharmacology at Harvard Medical School, says:

“We’re mimicking virus functionality to eventually build therapeutics that specifically target cells.”

The researchers believe the same cloaking method could be used to make artificial containers or “protocells” that could detect toxins in drinking water, or pathogens in food.

DNA is mostly known for its role as a conveyor of genetic information. But the researchers behind this latest study are looking at it differently – they see DNA as a 3D building material. They take strands of DNA and program them to fold into shapes, reminiscent of the Japanese paper-folding art of origami.

Specifically, they use their nanoscale origami skills to create DNA devices that are increasingly complex in shape, and approaching the intricacy of the molecular machinery found in cells.

The team is effectively building tiny robots out of DNA. These DNA nanorobots are capable of several functions: they can sense their environment, work out how to respond, then do something useful like trigger a chemical reaction, perform a movement or generate a mechanical force.

Such devices are not new. For example, in 2012, researchers at the Wyss Institute reported how they devised origami DNA nanorobots that target cancer cells and deliver instructions that make them commit suicide.

Also that year, scientists at Massachusetts Institute of Technology revealed how they devised nano-factories that could make drugs at tumor sites. Their nanoparticles produce proteins when ultraviolet light shines on them.

How to make DNA nanorobots invisible to immune system?

However, what has been missing is a way for nanorobots to evade the immune system – or at least hide from it long enough to be able to do their job. When Prof. Shih and colleagues injected nanorobots into the bloodstream of mice, their immune systems quickly found and digested them.

Prof. Shih, who is also an associate professor of Cancer Biology at the Dana-Farber Cancer Institute, says, that led them to ask, “How could we protect our particles from getting chewed up?”

They found the answer in nature. A virus hides from the host immune system with the help of a cloaking device. The virus protects its genome inside a solid protein coat covered in an oily protein – a double layer of phospholipid – identical to that contained in membranes surrounding the host’s living cells.

Prof. Shih says they wondered if enclosing their nanodevice inside such an envelope would have a similar effect.

To arrive at such a solution they first folded the DNA into a virus-sized octahedron, then built in handles on which to hang lipids, which then directed the double-layer membrane to assemble around the octahedron.

Nanodevice coated with lipid bilayer looked just like enveloped virus

The coated nanodevice looked just like an enveloped virus when seen through an electron microscope.

The next stage was to show the enveloped device could evade the immune system and survive in the body. To do this the devices were first loaded with dye, then injected into mice. Using whole body imaging, the researchers could track the nanodevices by seeing which parts of the mice glowed.

They also dyed and injected uncoated devices into another group of mice. These only glowed in the bladder area, showing that their immune systems had broken them down quickly and their bodies were ready to excrete their remnants.

But the mice that were injected with enveloped nanodevices told a different story. Their whole bodies glowed for hours, showing that the nanodevices stayed in the bloodstream for about the same length of time as effective drugs.

To show that the enveloped devices had also evaded the immune system, the researchers measured levels of two immune-activating molecules. The levels were 100 times higher in the mice that received uncoated nanodevices compared to the ones that received coated ones.

The researchers foresee cloaked nanorobots doing things like activating the immune system to fight cancer, or suppressing it to stop it rejecting transplanted tissue. They say that the main point is being able to control the immune system.

The National Institutes of Health, the US Army Research Laboratory’s Army Research Office, and the Wyss Institute at Harvard University contributed funds for the study.

In February 2014, Medical News Today reported on a study that used nanoparticles to target inflammation-causing immune cells. Researchers at the University of Illinois at Chicago have developed a system for precisely targeting out-of-control immune cells without interfering with correctly functioning immune cells.

Medicare Proposes Dollar Figure For New Chronic-Care Code

A Proposal That Could Reduce Revenue for Surgeons

Medicare would begin to pay physicians $41.92 a month next year for managing a patient with two or more chronic diseases outside of face-to-face office visits, according to a proposed physician fee schedule for 2015 released last week by the Centers for Medicare & Medicaid Services (CMS).

Last year CMS authorized a new billing code for chronic-care management to compensate physicians for tasks such as developing a care plan, referring patients to colleagues, and working with home-care agencies that are inadequately reimbursed under current evaluation and management (E/M) payment codes. CMS scheduled the code to take effect in 2015, but did not assign a dollar amount to it.

The proposed fee schedule for 2015 shows physicians the money, down to the cents. If a medical practice had only 20 Medicare patients who qualified for the new chronic-care management fee, it would gain an extra $10,000.

Physicians would bill Medicare for chronic-care management using a new G code. It would apply to at least 20 minutes of management services over 30 days for a patient whose multiple chronic conditions are expected to last at least 12 months, or until death, and that represent a significant risk for death, functional decline, or acute exacerbation or decompensation. Chronic-care services must be available on a 24/7 basis, but a clinical staff member can provide them at the midnight hour on an “incident-to” billing basis without direct supervision.

In the proposed fee schedule for 2015, CMS backed off from earlier notions to limit the new fee to physicians who employ at least one nurse practitioner or physician assistant, or who operate a medical home. However, CMS continued to make a case for requiring physicians to use an electronic health record (EHR) system that is certified under the agency’s meaningful-use incentive program.

Budgeting Medicare

CMS conceived the new billing code for chronic-care management as a way to support financially beleaguered primary care physicians. Another provision in the Medicare’s proposed fee schedule for 2015, however, could reduce revenue for surgeons. CMS wants to stop paying surgeons a set fee for procedures that covers postoperative services — think office visits — during 10-day and 90-day global periods. The agency is proposing that surgeons instead bill postoperative services separately on a piecemeal basis during these time frames.

What helped prompt this change, CMS explained, were reports from the Office of Inspector General in the US Department of Health & Human Services indicating that most surgeons did not perform as many postoperative services as the global period called for. For example, the fee for a 90-day global period may assume 10 postoperative office visits, but the surgeon may conduct only six.

CMS said it wants to convert both 10-day and 90-day global periods into 0-day periods, which would bundle all preoperative and postoperative care on the day of the surgery together with the operation itself. The 10-day global period would be phased out in 2017, the 90-day global period in 2018.
In a small victory for digital healthcare, CMS also said that it wants to expand the list of reimbursable services delivered via telemedicine to include annual wellness visits, psychoanalysis, psychotherapy, and prolonged E/M services. The agency said this change would improve access to healthcare in rural areas.

SOURCE: Medscape

Proposed Rule Would End Sunshine Act’s CME Exclusion

The CMS intends to eliminate the exclusion for continuing medical education in the Open Payments program, more commonly known as the Sunshine Act, which requires drug and device companies to disclose payments to physicians.

The reversal was included in the proposed Physician Fee Schedule for 2015, which also would make changes that would benefit primary-care medicine at the expense of payments to specialties.

The regulations also include a variety of changes to the Shared Savings Program service for accountable care organizations, the Physician Quality Reporting System and the incentive program for electronic health records. And it would expand the array of telehealth services that qualify for Medicare reimbursement.

The Open Payments Program

Sponsorships for CME were initially given a pass in the Open Payments program because the CMS believed adequate safeguards were already in place. Many experts, however, argued that the exclusion would allow drug and device companies to avoid disclosure by shifting marketing dollars to CME from direct promotional programs.

In the proposed rule, the CMS said “an unintended consequence” of the policy was the appearance the agency was tacitly endorsing corporate sponsorships of continuing education events. The Open Payments program stems from a provision of the Patient Protection and Affordable Care Act known as the Sunshine Act.

CME organizations and manufacturers that fund education events were blindsided by the move, said Andrew Rosenberg, senior adviser for the CME Coalition, a trade group.

“If it is allowed to stand, this policy change will be massively disruptive to every stakeholder in the CME ecosystem—doctors, educators and commercial supporters—who have spent over a year preparing for the implementation of the current rules,” Rosenberg wrote in an e-mail to Modern Healthcare late Friday. Extending the disclosure to CME, he added, would “discourage physicians from learning new medical science by creating a false stigma.”

Meanwhile, the rule’s suggested changes in the “relative value units” that determine Medicare payments to physicians must be revenue-neutral, so increases in payments in one area lead to cuts elsewhere.

Reclassification of Codes

The CMS proposed cutting Medicare payments for radiation therapy centers and radiation oncology services by 8% and 4% respectively by reclassifying equipment purchases as indirect expenses of providing care.

At the same time, the rule would increase payments for family practice (2%), internal medicine (2%) and geriatrics (1%), due to changes stemming from the CMS previously undervaluing the work required in those specialties, the proposal says. In addition, independent laboratories would get a 3% bump based on increases in the cost of running such an organization.

“Consistent with amendments to the Affordable Care Act, CMS has been engaged in a vigorous effort over the past several years to identify and review potentially misvalued codes, and to make adjustments where appropriate,” CMS officials said in a statement. “We identified most of these by reviewing high-expenditure services by specialty that have not been recently reviewed. Several other proposed services were identified in a variety of ways, including through our public nomination process.”

Robot Helps Save The Day At Rural Hospital

Some small, rural Kansas hospitals are using highly sophisticated medical robots in ways that are helping ease the shortage of specialists in their areas and – in at least one instance – boosting the bottom line.

Hamilton County Hospital here was on the brink of closing little more than a year ago because of financial and staffing problems, but use of a robot has been a key factor in the facility’s dramatic turnaround, according to chief executive Bryan Coffey.

“The reports of our demise are greatly exaggerated,” he said.

First order of business for Coffey when he became the administrator in June 2013 was hiring doctors for a hospital that had none. He recruited a primary care physician and a cardiologist.

Then “we brought in a telemedicine robot and started seeing a 180 (degree change). There’s been a 40 percent increase in (patient) volume and we’re consistently, month over month, 15 percent in growth,” Coffey said.

Coffey since has written a “white paper” on how small hospitals like Hamilton County’s can make the machines, which can easily cost $50,000 or more, a workable investment.

Hamilton County borders Colorado in southwest Kansas and has a population of about 2,700 people. The nearest major regional medical centers are in Denver and Wichita.

The robot now is being used at Hamilton County Hospital for a variety of purposes, including emergency room stroke treatment, dermatology and specialty pediatrics.

Coffey said the latter, done in partnership with Children’s Mercy Hospital in Kansas City, Mo., is “starting to grow hand over fist.”

‘Same page, same time’

The hospital now works with nine remote specialists, “and we’ve really just scratched the surface,” he said, noting that the machines make the sort of collaborative medicine that has been the hallmark of the Mayo and Cleveland clinics a possibility at all sorts of medical facilities, including small, rural hospitals.

“It puts everybody on the same page at the same time,” he said.

The robot connects distant doctors with patients and local medical providers in real time via a high-definition mobile visual display that includes various monitoring and imaging attachments such as a digital stethoscope. The hospital now is able to “beam in big-city care in a rural health care environment, all while saving the federal government money and lowering overall health care costs,” Coffey said, noting that many of the hospital’s patients are on Medicare.

The machine that makes it possible, he said, reminds him of the robot in the 2008 animated film “WALL-E” “but without the googley eyes.”

Tony Nunn at the University of Kansas Hospital in Kansas City, Kan., also is familiar with the robots thanks to a project he is working on with Hays Medical Center in central Kansas and Liberty Hospital, which is northeast of Kansas City, Mo.

KU Hospital stroke doctors will connect with patients via the robots in each of those hospitals, he said, once the new system goes live within a couple of weeks.

‘Like ‘The Jetsons’ on steroids’

The doctors will be available around the clock for remote consultations, he said, and able to link to the robot via iPads or laptop computers.

“It’s like ‘The Jetsons’ on steroids,” he said.

The robots at Hamilton County, Hays and Liberty are made by California-based InTouch Health.

Tim Hulen, the company’s sales representative for the Midwest, said the machines have been used by the military in Iraq and Afghanistan and were used at the Olympics, especially by “smaller countries whose specialists couldn’t make the trip but were still able to confer with their athletes” via the robots.

He said installing the machines and getting staff trained to use them is relatively easy.

“The thing that slows things down is licensing and credentialing,” he said. “We try to help the facility to see that they get everything done for billing and compensation. The device part is not that difficult.”

He said about 20 facilities in Kansas are using the company’s machines and about 10 more are expected to by early July.

But the number of InTouch or similar devices being used in small, critical access Kansas hospitals such as Hamilton County is thought to be low.

Innovation network

About a year ago, Stormont-Vail HealthCare in Topeka put an InTouch robot at Sabetha Community Hospital, which is in northeast Kansas near the Nebraska line.

The Sabetha hospital and Stormont are part of the Health Innovations Network of Kansas, which includes 19 facilities that primarily are small and rural. Stormont is the largest member.

Telemedicine experts say federal and state laws and regulations haven’t kept pace with the rapid changes in technology that now allow doctors to provide a variety of care to distant patients.

“I think eventually we won’t call it telemedicine. It will be just the way we deliver care,” said Morgan Waller of Children’s Mercy Hospital.

Meanwhile, policymakers lag behind the new realities.

“The laws are outdated,” Waller said. “The industry is developing so much faster than our state and federal legislatures can keep up with.”

Stormont bought and put the machine at the Sabetha hospital as part of a pilot project, according to Carol Wheeler, Stormont’s vice president of regional relations.

Stormont hospitalists are available for consultations with patients and providers in Sabetha via the robot.

“It started out being consultations in the emergency room,” Wheeler said, “but that was fairly quickly expanded to include inpatient consults as well. Our hospitalists through their control station are able to call up Sabetha and have a visualization of the patient at the bedside and talk with the (local) physician, the nurse and the patient, if necessary. They are essentially doing a consult as if they were there on the property.”

Wheeler said the machine so far hasn’t been used as frequently as had been hoped but that Sabetha hospital staff have shown interest in expanding its use to include consultations with Stormont’s specialists, which might make it busier.

“The docs out there would really like us to expand the specialty consults,” she said. “So we’re looking at the possibility of doing that as well.”

And other remote services could be considered.

“Some places are using them for psychiatric clinics, and that’s a wonderful possibility,” she said.

Stormont has offered the same arrangement to other hospitals in the network, though any takers in the second round of the initiative would be expected to buy their own robots.

Wheeler said none of the other network members has agreed to do it yet, though it is still early in the process.

“The cost of leasing the equipment is not insignificant,” she said.

Children’s Mercy began using the robots at its regional clinics in Wichita, St. Joseph and Joplin, Mo., to provide specialty and sub-specialty pediatric care. It now also can link in real time to a few other hospitals in Kansas and Missouri, said Morgan Waller, a registered nurse who is the director of telemedicine operations and professional services at Children’s Mercy.

“Beyond our original initiative … we are always looking for and receptive to (critical) access hospitals wanting to partner with us to increase their capacity, and Hamilton County is a beautiful example,” Waller said.

Seeing daylight now

The improvements at Hamilton County Hospital have not been lost on its board of volunteer trustees or others living in the close-knit community, according to Kent Schwieterman, the board chair.

Schwieterman is a former hog farmer who now works to maintain compression engines on the areas gas wells, which are atop a field that has dwindling output.

“Without this hospital (which is a major employer) it would be really hard to see any future” for Hamilton County, he said. “It’s pretty amazing from where we were a year ago or even around January. I was pretty fearful and wasn’t sure which direction we would go. We can see a lot of daylight now. I have a pretty good feeling about it.”

Original Story was posted on khi.org

The Health Insurance Marketplace Prepares For 2015 And Beyond

Today, we issued a final rule promoting affordability, transparency and taking the first step toward providing additional quality related tools for consumers shopping in the Health Insurance Marketplace.

We continue to be pleased with the success of the Marketplace in enrolling more than eight million consumers during this first open enrollment period. Building on that success and learning from this historic first enrollment period, the policies released today ensure that consumers, employers, and health insurance issuers have the guidance and information they need to prepare for next year and beyond.

CMS issues final 2019 Payment Notice Rule to increase access to affordable health plans for Americans suffering from high Obamacare premiums 
Final rule will improve program integrity, increase state flexibility, and reduce regulatory burdens

Today, the Centers for Medicare & Medicaid Services (CMS) issued the HHS Notice of Benefit and Payment Parameters for 2019. The final rule will mitigate the harmful impacts of Obamacare and empower states to regulate their insurance market. The rule will do this by advancing the Administration’s goals to increase state flexibility, improve affordability, strengthen program integrity, empower consumers, promote stability, and reduce unnecessary regulatory burdens imposed by the Patient Protection and Affordable Care Act.

“Too many Americans are facing skyrocketing premiums that they can’t afford and every year consumers are faced with the threat of fewer choices. This rule gives states new tools to stabilize their health insurance markets and empower citizens to find coverage that fits their families’ needs and budgets,” said CMS Administrator Seema Verma.

The Patient Protection and Affordable Care Act has led to higher premiums and fewer choices. Between 2013 and 2017, the average premiums more than doubled in the states using the Federal Health Insurance Exchange platform and half of the counties in America had only one issuer to choose from this year. The final rule provides states with the tools needed to help lower health premiums or, stabilize premium growth. The final rule will also enhance consumer choice by removing provisions that discourage issuers from offering plans that address the specific needs of Americans.

The final rule builds on the significant steps already taken by the Administration to promote health care choice and competition and decrease costs. Earlier this year, the Departments of Health and Human Services, Labor, and the Treasury published a proposed rule to expand the availability of short-term, limited-duration health insurance to provide consumers with more affordable options. CMS also issued the Market Stabilization Rule last year, which was implemented to lower premiums and increase consumer choice. All of this work is especially important at a time when the impact of the Patient Protection and Affordable Care Act has priced many consumers out of the insurance market.

The final rule issued today includes the following key provisions:

Increasing Flexibility

  • Essential Health Benefits (EHB): To allow insurers to offer more affordable health plans, CMS is providing states with additional flexibility in how they select their EHB-benchmark plan. The final rule provides states with substantially more options in what they can select as an EHB-benchmark plan. Instead of being limited to 10 options, states will now be able to choose from the 50 EHB-benchmark plans used for the 2017 plan year in other states or select specific EHB categories, such as drug coverage or hospitalization, from among the categories used for the 2017 plan year in other states.
  • States will also now be able to build their own set of benefits that could potentially become their EHB-benchmark plan, subject to certain scope of benefits requirements.
  • Qualified Health Plan (QHP) Certification Standards: The final rule returns important oversight authority to states regarding state review of network adequacy, and eases burden on issuers related to essential community providers. The rule also eliminates the meaningful difference requirement for QHPs to give insurers more flexibility in designing plans.

Improving Affordability

  • Exemptions: Exchanges will be able to make a determination of lack of affordable coverage based on projected income using the lowest cost Exchange metal level plan offered through the Exchange when there is no bronze level plan available in the service area.

Strengthening Program Integrity

  • Risk Adjustment: The final rule amends the HHS-operated risk adjustment data validation program to reduce burdens on issuers. In addition, the HHS-operated risk adjustment program is recalibrated for the 2019 benefit year to incorporate new data that reflects the actual experience of individual and small group market enrollees, which should more closely reflect the risk within markets. In States where HHS operates the risk adjustment program, CMS will also provide states with the flexibility to request a reduction to the otherwise applicable risk adjustment transfers in the individual, small group or merged market by up to 50 percent beginning with the 2020 benefit year, which may be helpful in attracting and retaining insurers and more precisely accounting for relative risk differences in the state market. States requesting such a reduction must provide evidence and analysis that show the state-specific rules or market dynamics warrant the adjustment to more precisely account for the relative risk differences in the State’s market and justifies the reduction amount requested.
  • Advanced Premium Tax Credit (APTC) Program Integrity: The final rule improves program integrity by requiring Exchanges to implement stronger checks to verify applicants actually earn the income they claim to qualify for APTCs. The rule also requires Exchanges to discontinue APTCs for enrollees who fail to file taxes and reconcile past APTCs, even if the Exchange does not first send notice directly to the tax filer.

Empowering Consumers

  • Special Enrollment Periods (SEPs): CMS is aligning the enrollment options for all dependents who are newly enrolling in Exchange coverage through an SEP and are being added to an application with current enrollees, regardless of the SEP the dependent qualifies under. For consumers newly gaining or becoming a dependent and enrolling through the birth, adoption, foster care placement, or court order SEPs, CMS amended and standardized the alternate coverage start date options available under all of these SEPs. CMS will also allow pregnant women who are receiving health care services through Children’s Health Insurance Program (CHIP) coverage for their unborn child to qualify for a loss of coverage SEP upon losing access to this coverage. Finally, CMS exempts consumers from the prior coverage requirement that applies to certain special enrollment periods if they lived in a service area without qualified health plans available through an Exchange.

Promoting Stability

  • Medical Loss Ratio (MLR): The final rule amends MLR requirements to reduce regulatory burden in order to stabilize insurance markets, increase insurer participation and expand consumer choice. Specifically, the rule reduces quality improvement activity reporting burdens on insurers and allows states to request reasonable adjustments to the MLR standard for the individual market if the state shows a lower MLR standard could help stabilize its individual insurance market.

Reducing Unnecessary Regulatory Burden

  • Small Business Health Options Program (SHOP): The final rule removes several regulatory requirements on SHOPs and outlines a new enrollment process in the SHOP Exchanges using the Federal platform. This change allows SHOPs to eliminate the online enrollment process and allows employers to enroll directly with an Exchange-registered agent, broker, or issuer and, the FF-SHOPs and SBE-FP for SHOPs will exercise the flexibilities outlined in the notice for plan years beginning on or after January 1, 2018. By January 1, 2017 only 7,600 employer groups, covering 39,000 lives, were in enrolled in the federal SHOP Exchange, far short of the 4 million people the Congressional Budget Office once projected would be enrolled by 2017. Turning over enrollment to qualified agents and brokers will help small business more easily enroll in coverage and lower costs.
  • Rate Review: The final rule increases the primary role of state regulators in the rate review process, while reducing the regulatory burden for states and issuers. The rule exempts student health insurance coverage from Federal rate review requirements, and raises the default threshold for review of reasonableness from 10 percent to 15 percent.

The Final Annual Issuer Letter was also released today. This Letter provides operational and technical guidance to issuers that want to offer Qualified Health Plans (QHPs) in the Federally-facilitated Exchanges (FFEs) for plan years beginning in 2019.

CMS also issued new guidance today expanding hardship exemptions. Under this hardship exemption guidance, individuals who live in counties with no issuers or only one issuer, will now qualify for a hardship exemption from paying the Affordable Care Act’s penalty for not having coverage.  The guidance also allows CMS to consider a broad range of circumstances that result in consumers needing hardship exemptions.

In addition, CMS issued a bulletin today to extend the transitional policy for one additional year. This policy allows for the transition to fully Affordable Care Act compliant coverage in the individual and small group health insurance markets until 2019.  CMS is releasing this bulletin to provide states additional flexibility and control over their health insurance markets.

To view the Final Annual Issuer Letter, please visit: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2019-Letter-to-Issuers.pdf

To view the Hardship Exemption guidance, please visit: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2018-Hardship-Exemption-Guidance.pdf

To view the Extended Transitional Policy guidance, please visit: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/Extension-Transitional-Policy-Through-CY2019.pdf

To view the Payment Notice Fact Sheet associated with this rule, please visit:https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-04-09.html

To view the Final Notice on the Federal Register, please visit: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-07355.pdf

VA Plan To End Rural Health Program Raises Hospital, Lawmaker Hackles

The U.S. Veteran Affairs Department appears to have no plans to continue a pilot program that it launched three years ago to give rural veterans access to private healthcare, despite calls for its continuance from some providers and lawmakers. Instead, it intends to transition the vets now using the pilot to a different program that some hospitals say puts them at financial risk since it reimburses at rates lower than Medicare’s.

The pilot initiative, known as Project ARCH (Access Received Closer to Home) began in 2011 and allowed some veterans to seek care with a private provider that had contracted with the VA. The pilot was available to veterans in certain areas who resided more than an hour’s drive from the nearest VA healthcare facility providing primary-care services and more than two hours’ drive from the nearest VA facility providing acute hospital care.

The Altarum Institute, a research organization, was hired in 2011 to evaluate the program throughout the pilot, offering tracking information on cost, quality and accessibility of care offered through the non-VA care providers. Depending on its findings, the expectation was the program would expand, the company says. ARCH had a 90% approval rate by veterans, according to Altarum.

But ARCH is coming to an end while lawmakers are working on combining a House and Senate veterans’ health bill that, among other things, would allow veterans to visit private doctors at VA’s expense if they are unable to get an appointment in a timely manner or live more than 40 miles from a VA facility.

Some lawmakers want ARCH to continue because they fear vets now using it could see a lapse in care before any new program is put in place as a result of congressional action. Even if a deal on a bill can be reached, and it passes both houses and is signed by the president by early July, the subsequent rulemaking process to implement the law could be lengthy.

The VA is concerned about its ability to handle the administrative burden of implementation of the non-VA provisions in the House and Senate bills, Philip Matkovsky, assistant deputy undersecretary for health for administrative operations at the Veterans Health Administration, testified Wednesday at a House Veterans’ Affairs Committee hearing.

ARCH was limited to five pilot sites: Billings, Mont.; Farmville, Va.; Flagstaff, Ariz.; Pratt, Kan.; and northern Maine. Had the program expanded, as many as 3.2 million rural veterans now enrolled in the VA healthcare system could have potentially benefited.

The program will end Aug. 29. The VA is creating individual transition plans for each veteran in the pilot, Matkovsky said at the hearing Wednesday. The agency did not release data on how many vets are currently in the program or the amount of money spent on ARCH to date.

The VA feels that an initiative it launched late last year, known as Patient-Centered Community Care, or PC3, will largely fill the void left by ARCH. PC3, among other provisions, provides rural veterans coverage for inpatient and outpatient medical and surgical specialty care. The agency however, is still investigating how to best help those relying on ARCH for primary care, as that’s not currently covered in the PC3 program.

Under PC3, the Veterans Health Administration contracts with managed healthcare organizations Health Net and TriWest to develop and oversee a network of providers who deliver specialty, mental health and limited emergency care.

However, some of the hospital participants in ARCH contend switching to PC3 could hurt their bottom lines. During the Wednesday hearing, Kris Doody, CEO of Cary Medical Center in Caribou, Maine, said that her facility has thus far declined to become part of PC3 because of its low reimbursement rates.

She preferred ARCH, she said, because in it a hospital contracts directly with the VA and receives Medicare equivalent rates. Health Net, which is overseeing PC3 in her area, is offering payments below Medicare rates. Lawmakers anecdotally had heard concerns that this was happening in other parts of the country.

Since Maine already has Medicare rates lower than many other states, it wouldn’t be financially feasible to accept Health Net’s offer, Doody said. A report released earlier this month by the CMS revealed that Maine’s total Medicare expenditures per capita were 17% lower than the national average.

Doody had relayed similar concerns to Sens. Susan Collins (R-Maine) and Angus King (I-Maine), who in turn sent a letter (PDF) June 9 to acting Secretary of Veterans Affairs Sloan Gibson asking that he extend ARCH. Early indications are that PC3 is not being used in Maine, they said.

“PC3 has been operational in Maine for two months, but statistics show that it is not meeting the needs of highly rural veterans who are most in need of this program,” the lawmakers say. “According to the VA’s own data, in the first month of its operation not one veteran in Maine had used PC3 during this time period. We are concerned that the low rate of reimbursement offered by Health Net could preclude PC3 from being an adequate successor to ARCH.”

Collins and King sent another letter a few days later co-signed by Sens. Jerry Moran (R-Kan.) Jon Tester (D-Mont.) and John McCain (R-Ariz.) also pushing to continue ARCH.

“For reasons we do not understand, the VHA is choosing—at VHA’s own initiative—to end this successful program,” the letter (PDF) reads. “All along, the VHA gave us the impression that it was waiting on analysis about the success of ARCH to inform its decision about extending the program. We are deeply disappointed by this breach of trust because those who suffer from this recklessness are veterans.”