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December 2014 Archives

December 3, 2014

CMS Proposes Revisions to ACO Regs

The Centers for Medicare & Medicaid Services (CMS) has informally posted proposed revisions to the Medicare Shared Savings Program including provisions relating to the payment of Accountable Care Organizations (ACOs). The formal comment period for the revisions will not begin until the regulations are actually published in the Federal Register. Read the proposed regulations here.

Update December 12, 2014 - The regulations were published in the December 8, 2014 Federal Register. Read the regulations here. Comments are due no later than February 6, 2015.

December 12, 2014

Gilead Sued Over Hepatitis-C Drug Pricing

In a case that will assuredly be watched very carefully, the Southeastern Pennsylvania Transportation Authority (SEPTA) has sued drugmaker Gilead Sciences, Inc. over the pricing of its Hepatitis C drug Solvadi®. SEPTA claims that Gilead's patent rights "do not translate into a license to price gouge consumers, state and federal health and welfare programs, and other third party payers under the extraordinary circumstances presented here."

The Pennsylvania Record has a nice writeup here. Link to the complaint here courtesy of the Washington Post.

The class action complaint alleges (among other things) that a standard 12-week regiment of Solvadi in the United States costs $84,000, while the same drug sold in Egypt costs $900.

December 15, 2014

Insurance Circular Letter on Coverage of Gender Dysphoria

The New York Department of Financial Services has issued a circular letter to provide guidance regarding health insurance coverage for the treatment of gender dysphoria. The circular letter summarizes itself:

An issuer may not deny medically necessary treatment otherwise covered by a health insurance policy or contract ("policy") solely on the basis that the treatment is for gender dysphoria. Further, an issuer is required to provide an insured with the full range of utilization review appeal rights as described in Article 49 of both the Insurance Law and the Public Health Law (collectively, "Article 49") for any gender dysphoria treatment that is denied based on medical necessity.

The letter further provides this definition of gender dysphoria: ""Gender dysphoria" is the term currently used for the condition of people whose gender at birth is contrary to the one with which they identify." Read the full letter on the DFS website.

New York Health Centers Net $2.8 Million in ACA Grants

The U.S. Department of Health and Human Services announced the award of $36.3 million in Affordable Care Act funding grants, $2.8 million of which went to 56 health centers in New York. The largest grant of $158,000 went to Bronx Lebanon Integrated Service System, Inc. (BLISS), a nonprofit health center organized in 1996 to provide medical, dental, social, and substance abuse services primarily to residents of the south and central sections of The Bronx. To see all of the New York health centers receiving funds, visit the listing on HRSA's website.

December 17, 2014

SUNY Foundation to Pay $4 Million for Falsifying Medicaid Data

From John O'Brien at Syracuse.com:

An agency tied to the State University of New York has agreed to pay the federal government $3.75 million to settle claims that its employees doctored audits to hide the number of ineligible people receiving Medicaid benefits.

Federal prosecutors accused the Research Foundation of SUNY of falsifying its audits of how efficiently the state was running its Medicaid program between October 2007 and September 2008.

Read the full article on the Syracuse.com website.

New York Gets an "F" For Physician Quality Transparency

Becker's Hospital Review notes a recent study that gives New York an F for physician quality transparency.

The Health Care Incentives Improvement Institute flunked 40 states and Washington, D.C., and gave four states a "D" in providing objective, publically accessible information on physician quality, based on a recent study.

Transparent information is available for only 16 percent of clinicians on average, according to the report. There is no data available in some states.

The report, available here, indicates that transparent quality data is available for only 12 percent of New York clinicians, 4 points below the national average. Factors such as the availability and understandability of the data were also considered in the final grade. New York scored an 8 overall, compared to Massachusetts' 40 and California's 52.

December 22, 2014

Forty-one New York Hospitals Face Medicare Cuts for Poor HAC Scores

Kaiser Health News is reporting that 721 hospitals will receive a 1% reduction in their Medicare reimbursement for FY2015 due to poor hospital-acquired condition (HAC) scores.

In New York, 41 of the state's 157 hospitals will experience the reduction. The penalties for all 721 hospitals will amount to $373 million.

HAC scores across all 3284 hospitals in the nation ranged from 10 to 1, with 10 being the worst. Only one New York hospital -- Massena Memorial Hospital in St. Lawrence County -- fell into the "10" category. Three New York hospitals tied with the lowest score of 1, including Bon Secours Community Hospital in Orange County, the Hospital for Special Surgery in New York City, and St. Mary's Healthcare in Montgomery County.

The complete data download is available at the Kaiser Healthnews website.

Governor Releases Medical Marijuana Regulations

On Thursday, December 18 Governor Cuomo released draft regulations for the State's medical marijuana program.

The regulations will be published in the December 31, 2014 State Register. The regulations will be open to a 45-day public comment period after that.

See the Governor's press release here or link straight to the draft regulations.

December 23, 2014

Obama Administration Investigating Discriminatory Benefit Designs

Yesterday's New York Times reports that the Obama administration intends to investigate companies in the federal insurance marketplace it suspects of engaging in unlawful discrimination against people with AIDS, mental illness, diabetes and other costly chronic conditions.

The administration intends to focus benefit design aspects such as formulary structure, member cost-sharing, and prospective utilization review.

Read the full NY Times article here.

About December 2014

This page contains all entries posted to HEALTH LAW SECTION BLOG in December 2014. They are listed from oldest to newest.

August 2012 is the previous archive.

January 2015 is the next archive.

Many more can be found on the main index page or by looking through the archives.