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.

December 22, 2014

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.

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.

December 17, 2014

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.

SUNY Foundation to Pay $4 Million for Falsifying Medicaid Data

From John O'Brien at

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 website.

December 15, 2014

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.

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.

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 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.

August 31, 2012

More than $2 Million Awarded to New York State Health Care Providers to Address Doctor Shortages

On August 30, 2012, the New York State Department of Health (DOH) announced "Doctors Across New York" (DANY) program grants to 21 hospitals, health centers, medical practices, and physicians for physician recruitment in underserved areas of the state. The grants, totaling $2,052,383, ranged from $65,377 for Bianca D. Van Kust, M.D. in Manhattan to $200,000 for The Woman's Christian Association in Chautauqua. Other recipients include St. Barnabas Hospital in the Bronx, Adirondack Medical Center in Essex County, and Oneida Health Systems in Oneida County.

Read the press release from DOH, with more information about the DANY program and a full list of award recipients and grant amounts, here.

August 24, 2012

DOH's "Get-Tough Approach" to Medicaid Managed Care Plans

A recent Businessweek article examined New York State's approach to improving the quality of care provided by Medicaid managed care plans such as WellCare. In the article, Jason Helgerson, the state's Medicaid Director, elaborates on DOH's enforcement strategy. The article highlights the predominance of not-for-profit plans, payments for good performance, and the state's 85 percent MLR requirement for Medicaid managed care plans as reasons why New York is succeeding where other states have not.

For those of you with experience representing Medicaid plans in New York as well as other states, how does DOH's approach to quality compare to the approach taken by other states?

August 21, 2012

Doctors May Prescribe Apps to Patients for Disease Management

The Greater New York Hospital Association (GNYHA) was prominently featured in a New York Times article discussing the role of apps in managing chronic diseases such as diabetes, and the FDA's role in approving them.

Read the article here.

What would you advise a physician client who wants to prescribe apps to his or her patients?

June 11, 2012

KHN/USA Today: GNYHA Members May Ask for Medicare Money Back if Mandate is Eliminated from ACA

A Kaiser Health News / USA Today article about the potential effects of a Supreme Court decision striking down the ACA's individual mandate quotes Greater New York Hospital Association president and CEO Kenneth Raske as saying of the Medicare funding cuts that were used to fund the law's insurance coverage provisions:

"The cuts were used to finance the expansion, and if the expansion doesn't occur, what are the cuts financing? Nothing," Raske says. If the mandate is removed, he says Capitol Hill "will hear a legitimate and concerted voice from the hospital community to kill the cuts."

Read the article here.

"I-STOP" Legislation passes both houses

The Governor's Program bill designed to address the problem of prescription drug abuse was introduced Friday evening after months of discussions and negotiations. The bill (available here) passed both houses today. The legislation greatly expands the state's prescription monitoring program, requires electronic prescribing, reschedules certain controlled substances and tasks the prescription drug workgroup established by this year's budget with additional consultative responsibilities, including guidance regarding education and continuing education for health care practitioners.

May 22, 2012

Study: Untrained Medical Interpreters Cause More "Clinically Significant" Errors

An article in today's Washington Post highlighted a recent Annals of Emergency Medicine study that found that "ad hoc [as opposed to trained] interpreters make nearly twice as many potentially clinically significant interpreting errors as do trained interpreters." According to the article, the study also suggested that the risk of clinically significant errors was lower with no interpreter than with an untrained one. The article also discussed the potential civil rights implications of a failure to provide adequate interpreter services to patients.

Read the Washington Post article here.

For additional posts, see the archive headings in the right hand column.