CMS Releases Medicare Advantage Final Call Letter for 2015
On April 7, 2014, the Centers for Medicare and Medicaid Services (CMS) released the "Announcement of Calendar Year (CY) 2015 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter," which outlines the payment and risk adjustment methodology changes that will affect payments for Medicare Advantage Organizations (MAOs) and Medicare Part D plans in 2015. The Final Call Letter includes several deviations from CMS's February 21, 2014 "Advance Notice of Methodological Changes for Calendar Year (CY) 2015 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter."
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St. Luke's Health System Ordered to Unwind Acquisition of Physician Group
As healthcare reform continues to incentivize the consolidation of the healthcare industry in order to further integrate and coordinate care, courts have had to then evaluate these consolidations under federal antitrust laws to prevent anticompetitive effects. On January 24, 2014, a federal judge in Idaho sided with the Federal Trade Commission (FTC) in ruling that Idaho's largest health system, St. Luke's Health System, violated federal antitrust law when it acquired one of the largest physician multi-specialty groups in the state in 2012, and ordered the parties to unwind the acquisition. This case may lead hospitals and other healthcare providers to closely examine potential antitrust issues before a merger or acquisition. While the primary intention behind many consolidations is to integrate care in compliance with the Affordable Care Act (ACA), this case establishes that compliance with the ACA alone may not be a defense against antitrust prosecutions. (Read more...)

OIG Reports Fraud Vulnerabilities in Electronic Health Records
A report entitled, "CMS and its Contractors Have Adopted Few Program Integrity Practices to Address Vulnerabilities in EHRs," highlighting the vulnerabilities associated with electronic health records, which criticized the Centers for Medicare and Medicaid Services (CMS) for its failure to adopt sufficient guidelines to prevent and detect fraud associated with EHRs, was published on January 8, 2014 by the Department of Health and Human Services Office of Inspector General. This January 2014 Report was not the first publication to discuss potential EHR liability. In fact, it is a companion follow up report to a December 2013 report regarding the use of the "copy-paste" feature by hospitals in their EHR technology, which "could pose a fraud vulnerability." (Read more...)

Decreasing Marginal Utility in Healthcare Series, Part 2 of 3: Causes of Wasteful Spending in the U.S. Healthcare System
The first article of this three-part Health Capital Topics series on the decreasing marginal utility in healthcare, discussed the exponential increase of U.S. healthcare expenditures in recent years, which has not necessarily resulted in better health outcomes for the U.S. population. One approach to increasing the "value per dollar" spent on healthcare is to reduce wasteful spending in the healthcare system. Reducing this wasteful spending necessitates the identification of the various types of waste in the U.S. healthcare system. The second installment of this three-part series examines the different sources of waste that have allowed such inefficient and unsustainable healthcare spending to thrive in the U.S. despite the declining yield on investment. (Read more...)