The Exchange Morass: What Worked, What Didn’t, and What to Expect


Piper Su, Vice President for Healthcare Policy at The Advisory Board Company, discusses exchanges at the 2014 CareCore National Healthcare Summit. 

The highlights from her talk, listed below, were written by CareCore’s Dunston Almeida.

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CareCore Ice Bucket Challenge


The 2014 ALS Ice Bucket Challenge has taken the social media sphere by storm. Here at CareCore, we proudly support this awareness effort. ALS affects nearly 30,000 people living in the US with 5,600 new patients being diagnosed each year. With no known cause or trigger for the disease, we currently have no cure.

We hope that our efforts—along with the thousands of other people that have participated in this awareness challenge—will positively impact the lives of everyone affected by this devastating disease. It is truly empowering to witness the nation coming together for such a great cause.

Our mentors and mentees gathered together Friday afternoon to raise awareness. We challenge our executive team, leadership team and our CO, CA, and NY offices!

This week in healthcare – News from around the web

Cancer studies often downplay chemo side effects – In two-thirds of the 164 studies Tannock and his colleagues scrutinized, that meant not listing toxicities – in other words, serious side effects whether of chemotherapy, radiation or surgery – in the paper’s abstract.

U.S. could save $2 trillion on health costs – Compiled by the nonpartisan Commonwealth Fund, the study recommends holding the $2.8 trillion U.S. healthcare system to an annual spending target by having Medicare, Medicaid, other government programs and private insurers encourage providers to accelerate adoption of more cost-effective care.

Pre-surgery MRI may harm breast cancer patients – Routinely using the technology once any woman is diagnosed with a tumor may lead to more radical surgery without any benefits, says a team of Australian and U.S. researchers.

This week in healthcare – News from around the web

Dramatically influence drug prices by positive action – Drug maker admitted their price point was too high. But rather than lower the price they chose to share the profits with the provider in return for market share. This means that patients still have to cover their $2200 a month copay and that Medicare still pays the full amount.

Out-of-Network Bills for In-Network Health Care – The robo-call from the physicians’ billing service had the intended effect: I panicked. It sounded like a collection agency. I almost paid what it asked. When there’s a difference between the charge and the insurance reimbursement, and a health care provider tries to collect the difference from the patient — that is balance billing. Critics call it a huge problem.

Asymptomatic Carotid Ultrasonography Jumps, and With it, More Endarterectomies and Stenting - Physician self-interest may be a factor in the shift toward use of carotid artery ultrasonography to identify patients for vascular interventions. Diagnostic radiologists and self-referring cardiologists, vascular surgeons, and interventional radiologists may have benefitted financially from the procedures.

Curbing hospital readmission rates
New Efforts to Close Hospitals’ Revolving Doors – Hospitals are dispatching nurses, transportation, culturally specific diet tips, free medications and even bathroom scales to patients deemed at risk of relapsing. Readmission rates have decreased, in some months by as much as half.

Hospitals Face Pressure to Avert Readmissions – With nearly one in five Medicare patients returning to the hospital within a month — about two million people a year — readmissions cost the government more than $17 billion annually.

CareCore National Donates to Hurricane Sandy Relief Efforts

November 7, 2012

CareCore National joined with other South Carolina Lowcountry organizations to send relief supplies Continue reading

This week in healthcare – News from around the web

Study finds “dramatic” rise in kids’ CT scans – Emergency rooms across the U.S. have seen a steep increase in CT scans of kids presenting with belly ache, while the appendicitis rate hasn’t budged.

Why hospital pricing practices concern me – It behooves us all to comparison shop whenever possible before undergoing any kind of non-urgent hospital procedure.

Hospitals face fines over too many readmitted Medicare patients – It adds up to a new way of doing business for hospitals, and they have scrambled to prepare for well over a year. They are working on ways to improve communication with rehabilitation centers and doctors who follow patients after they’re released, as well as connecting individually with patients.

Hospitals of the future in the making – In the hospital of the future, data centers will also be supported and managed virtually. The cloud will move beyond a private model to support public and private capabilities. Healthcare IT will not need to be housed in the hospital of the future. Rather, it may be provisioned from multiple locations in a community or around the globe.

GAO attacks imaging self-referral, requests pay cut for exams


Aunt Minnie examines the recent GAO report taking a close look at self-referral for medical diagnostic imaging.

GAO attacks imaging self-referral, requests pay cut for exams

By Brian Casey, staff writer

November 1, 2012 — A new report from the U.S. Government Accountability Office (GAO) takes a hard-line on physician self-referral of imaging services, detailing more than $100 million in annual unnecessary spending in CT and MRI alone. The report recommends steps to curb the practice, including a pay cut for self-referred imaging studies.

Physician self-referral of patients to imaging scanners that they purchase or lease is a hotly contested topic. The practice is allowed through a loophole in the Stark anti-self-referral act, and proponents claim it offers convenience to patients who don’t have to be referred to another facility for imaging exams.

Opponents, however, believe it leads to wasteful spending as non-radiologist physicians order imaging exams for economic rather than clinical reasons. Radiology advocates have long requested that the U.S. government address physician self-referral as part of its efforts to control wasteful healthcare spending.

The GAO report is a sign that the government may be listening. The report was commissioned due to concerns over Medicare Part B expenditures — including those for advanced imaging services — which “are expected to continue growing at an unsustainable rate,” according to the report. The GAO said it was asked to examine the prevalence of imaging self-referral and its impact on Medicare spending.

The GAO report analyzed Part B claims data from 2004 through 2010, specifically focusing on CT and MRI services. The report found that the overall incidence of self-referral grew during the period, with the number of self-referred MRI studies increasing by 80% over the study period, compared to growth of 12% for MRI scans that weren’t self-referred.

In addition, healthcare providers who began to self-refer saw imaging volume spike shortly after they began the practice. Providers who began self-referring in 2009 increased their CT and MRI referrals by 67.3% in 2010 compared to 2008, and the average number of referrals increased from 25.1 to 42.0 during those years.

In comparison, physicians who were already self-referring in 2009 saw their imaging volumes drop 3.4%, from an average of 47.0 referrals in 2008 to an average of 45.4 referrals in 2010. For providers who weren’t self-referring at all, imaging volumes fell 6.8%, from 20.6 referrals in 2008 to 19.2 in 2010. The findings suggest that the increase was not due to an overall rise among all providers, according to the GAO.

The report estimates that in 2010, healthcare providers who self-referred likely made 400,000 more referrals for advanced imaging studies than they would have if they were not self-referring, and these referrals probably cost Medicare $109 million. The referrals are particularly problematic for CT, as they are exposing patients unnecessarily to ionizing radiation.

The report makes several recommendations to help the U.S. Centers for Medicare and Medicaid Services (CMS) identify and rein in self-referred imaging studies:

  • · The CMS administrator should insert a flag to identify self-referred imaging studies on Medicare Part B claims forms. Providers should be required to indicate whether the services for which they are billing are self-referred.
  • · CMS should implement a payment reduction for self-referred advanced imaging studies to recognize the efficiencies that occur when the same provider refers and performs a service.
  • · CMS should develop tools for ensuring the appropriateness of self-referred imaging services.

Response to the report was mixed. The Medical Imaging and Technology Alliance (MITA), which represents scanner vendors, found fault with the report, stating that two of the recommendations were “unworkable and unnecessary.” The report also failed to acknowledge that per capita imaging utilization has declined, and it failed to address patient access to imaging.

MITA believes that qualified physicians should be able to provide appropriate imaging services to their physicians regardless of their specialties — to do otherwise would limit patient access to care. MITA also noted that the U.S. Department of Health and Human Services (HHS) has agreed to examine the appropriateness issue, which MITA believes is best tackled through appropriateness criteria developed by physicians.

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