We found that small practices did not perform as well as larger practices in the previous incentive programs. Medicare estimates that small practices will do better under MIPS in part because the new system offers increased flexibility, such as allowing practices with 10 or fewer providers to participate as a virtual group that can work together and share resources with small practices in other areas of the country.
To have their drugs covered under Medicaid, the "340B" program requires drug manufacturers to sell outpatient drugs to covered entities—certain hospitals and clinics—at a discount. These entities are increasingly contracting with pharmacies to dispense 340B drugs. Doing so can make it harder to ensure compliance with 340B rules. For example, contract pharmacies may also fill prescriptions for the general public, increasing the risk of dispensing 340B drugs to ineligible patients.
This report provides an update on the nation's fiscal health as of the end of fiscal year 2017, and describes its likely fiscal future if policies don’t change. Among its findings:
Medicaid paid $171 billion—about half its total 2017 federal expenditures—to managed care organizations. The Centers for Medicare & Medicaid Services estimated that about 0.3% of that amount were improper payments.
For the entire Medicaid program, CMS estimated about 10% of payments were improper, which led us to question the managed care rate.
We examined state and federal reviews of managed care and the estimating method. We found that the estimation does not fully account for key risks such as overpayments and unallowable costs.
What can Medicare do to help address the nation's opioid crisis?
We've previously found problems such as "doctor shopping" and questionable prescribing practices in Medicare's prescription drug benefits. 14.4 million people were prescribed at least one opioid through Medicare in 2016. While many opioids prescribed addressed legitimate need, others may have been overprescribed.
In an effort to reduce improper payments and reduce expenses, the Medicare program has experimented with requiring prior authorization. This means beneficiaries need approval before they can receive certain services or items like powered wheelchairs.
We found this approach, which started in 7 states in 2012, reduced spending on these items and services by as much as $1.9 billion. Providers and suppliers reported benefits from the approach, but also had concerns about uncertainties created over what is covered.
Improper payments have continued to grow in the Medicaid program, despite efforts to reduce them. The federal-state health care program spent about $596 billion in FY2017, with an estimated $37 billion of federal spending going to improper payments—that's up from $29.1 billion in 2015.
GAO recommends that CMS develop additional guidance for researchers on implementing security controls required by CMS, consistently track results of independent assessments, and provide oversight of researchers and qualified entities. CMS concurred with GAO's three recommendations and described actions it has planned or taken to address them.
The Patient Protection and Affordable Care Act established a fund to support research comparing the effectiveness of available treatments. This research can help patients, doctors, and others make decisions to improve health care.
To carry out its mission, GAO has four overall strategic goals that focus on 1) the well-being and financial security of the American people; 2) threats and challenges associated with national security and global interdependence; 3) transforming the federal government to address national challenges; and 4) maximizing the value of GAO as a leading practices federal agency.
In addition to this document, please see the other two components of GAO's 2018-2023 strategic plan:
About one-third of Medicaid's spending goes toward demonstrations, which allow states to test new approaches to delivering Medicaid services. Do they save money? Improve care?
The short answer is that states and the federal government don't fully know. We found that the federal government did not require complete and timely evaluations from the states, so conclusive results were not available. Moreover, the federal government wasn't making its evaluation results public—missing opportunities to inform federal and state Medicaid policy discussions.
Medicare beneficiaries must cover a portion of the costs of services they receive. The rules governing traditional Medicare’s cost-sharing have changed little since the program began in 1965, while private insurance has evolved to include features that traditional Medicare lacks, such as an annual cap on the costs for which beneficiaries are responsible.
About two-thirds of inmates with a serious mental illness in the Department of Justice's (DOJ) Federal Bureau of Prisons (BOP) were incarcerated for four types of offenses—drug (23 percent), sex offenses (18 percent), weapons and explosives (17 percent), and robbery (8 percent)—as of May 27, 2017. GAO's analysis found that BOP inmates with serious mental illness were incarcerated for sex offenses, robbery, and homicide/aggravated assault at about twice the rate of inmates without serious mental illness, and were incarcerated for drug and immigration offenses at about half or less the rate of inmates without serious mental illness. GAO also analyzed available data on three selected states' inmate populations and the most common crimes committed by inmates with serious mental illness varied from state to state due to different law enforcement priorities, definitions of serious mental illness and methods of tracking categories of crime in their respective data systems.
Older people and people with disabilities receiving Medicaid assisted living services—over 330,000 in 2014—can be vulnerable to abuse, neglect or exploitation. The Centers for Medicare & Medicaid Services oversees how states monitor such incidents, but its guidance has been unclear.
By law, the amount Medicare pays for a Part B drug is generally based on the drug’s market price, no matter how high or low that price may be. Therefore, when Medicare accounts for a large share of a drug's market, the manufacturer may have less incentive to price the drug competitively.
Medicaid spent $87 billion in FY2015 for long term care services provided in homes and community settings. To receive these services, individuals’ needs must first be assessed—by a government agency, independent contractor, care provider, or others.
We looked into changes in the drug industry and found that pharmaceutical and biotechnology sales revenue increased from $534 billion to $775 billion between 2006 and 2015. Additionally, 67% of drug companies increased their annual profit margins during the same period—with margins up to 20 percent for some companies in certain years. Drug industry spending for research and development increased from $82 billion in 2008 to $89 billion in 2014.
State-reported data help the federal government oversee the Medicaid program, which made an estimated $36.7 billion in payment errors in 2017. However, there have been longstanding concerns that those data are not sufficient for effective oversight.
We recommended federal administrators take steps to expedite collection of complete and comparable data, and draft a plan for how they will use the data.
We examined whether automatic re-enrollment could have unintended financial consequences for consumers. We found that, from 2015 to 2016, the median monthly premium increase for those who were automatically re-enrolled, after tax credits, was $22; for those who actively re-enrolled, the increase was $5, partly because they may have switched to less expensive plans.
GAO's Fraud Risk Framework and the subsequent enactment of the Fraud Reduction and Data Analytics Act of 2015 have called attention to the importance of federal agencies' antifraud efforts. This report examines (1) CMS's approach for managing fraud risks across its four principal programs, and (2) how CMS's efforts managing fraud risks in Medicare and Medicaid align with the Fraud Risk Framework.
A 2010 federal law authorized pharmacies and other entities to voluntarily maintain a prescription drug disposal bin for the public. We found that 3% of entities eligible to collect drugs in this way volunteered to do so. Stakeholders reported that this is partly due to the cost of purchasing a bin and paying for the destruction of collected drugs.
Over 52,000 people died of drug overdoses in 2015—and 63% of these involved opioids. For those who are addicted to or misuse opioids, medication-assisted treatment (MAT)—behavioral therapy combined with medication (such as buprenorphine)—can help. However, many people who need it don't have access to it.
More than 14 million people received opioid prescriptions in 2016 through the Medicare drug benefit program, Part D.The Centers for Medicare & Medicaid Services delegate monitoring of these beneficiaries to the private organizations that implement the Medicare Part D benefit. These organizations follow CMS monitoring criteria.
The Office of Inspector General's (OIG) work planning process is dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available.
The Centers for Medicare & Medicaid Services has an IT system—the Fraud Prevention System— that analyzes claims to identify health care providers with suspect billing patterns. Program integrity contractors get leads from the system to pursue fraud investigations.
Medicaid beneficiaries who need long-term care can get it in their homes, community settings, or an institution such as a nursing home. Many states contract with managed care organizations to provide this care.
The 6 states we reviewed used various methods (e.g., beneficiary surveys) to monitor access and quality in managed long-term care programs. However, the Centers for Medicare & Medicaid Services did not always require the states to report information it needs for oversight, such as beneficiary concerns or whether there are enough providers.
Nearly 1 in 3 Americans relies on Medicare or Medicaid for services from hospital stays and lab tests to flu shots and prescription drugs. The Centers for Medicare and Medicaid Services uses an extensive network of private contractors to administer its programs.
In FY 2016, CMS spent about $7.2 billion on these contracts, an increase of about 40% since 2012. We found that 97% of this amount went to services, such as IT and administrative support. Additionally, since competition in government contracting generally saves money, CMS increased its use of competitive contracts from 78% to 96% during this same period.
Federal and state Medicaid spending on behavioral health services—mental health and substance use treatments—is projected to be $71 billion in 2017.
However, some adults on Medicaid may have limited access to inpatient or residential behavioral health care because Medicaid generally doesn't cover services for adults in institutions for mental disease.
BOP lacks or does not analyze certain health care data necessary to understand and control its costs. For example, while BOP's data can show how much BOP is spending overall on health care provided inside and outside an institution, BOP lacks utilization data, which is data that shows how much it is spending on individual inmate's health care or how much it is expending on a particular health care service. BOP has identified potential solutions for gathering utilization data, but has not conducted a cost-effectiveness analysis of these solutions to identify the most effective solution.
The Secretary of Transportation should: (1) communicate a method to receive air ambulance, including balance billing, complaints; (2) take steps to make complaint information publicly available; (3) assess available data and determine what information could assist in the evaluation of future complaints; and (4) consider air ambulance consumer disclosure requirements.
Behavioral health conditions disproportionately affect low-income people. Some states expanded Medicaid to cover low-income adults, as authorized by the Affordable Care Act, so we examined how many people in this expansion group received behavioral health treatment.
Medicare pays for some two-way video visits—referred to as "telehealth"—if the patients connect from rural health facilities. Medicare is testing new ways to provide health care that allow telehealth coverage regardless of location.
The Centers for Medicare & Medicaid Services estimates that about $16 billion or nearly 10% of its payments to Medicare Advantage organizations were improper. In this testimony, we reviewed several problems we have found with CMS's efforts to ensure proper payments in this program that serves about a third of Medicare beneficiaries.
FDA's expanded access program allows patients with serious or life threatening illnesses access to certain drugs before it has approved them. FDA also requires that manufacturers submit data about adverse reactions to these drugs. While FDA has provided some guidance to manufacturers, FDA does not fully explain the few instances when it would use these data on adverse reactions. This may influence manufacturers' decisions to give these drugs to patients due to concerns that adverse reactions will result in FDA placing a hold on their drug.
Despite the program's intention to reward hospitals that provide high-quality care at a lower cost, we found that some hospitals with low quality scores received bonuses because they had relatively high efficiency scores.
The Department of Veterans Affairs (VA) has system capabilities through multiple computer applications that support its clinicians and pharmacists in prescribing and dispensing medications to patients. However, pharmacists cannot always efficiently view necessary patient data among Veterans Health Administration (VHA) medical sites. In addition, pharmacists cannot transfer prescriptions to other VHA pharmacies or process prescription refills received from other VHA medical sites through the system. As a result, the system does not provide important capabilities for pharmacists to make clinical decisions about prescriptions efficiently, which could negatively affect patient safety.
FDA launched a mobile application (app) to offer access to National Drug Code (NDC) data from phones or tablets. The new app, NDC Express, presents the NDC database in a mobile-friendly format, using display and navigation features available in both Android and iOS devices.
We found some contracts in which people in poor health were much more likely than others to voluntarily leave the contracts' health plans. These contracts generally had lower quality scores, and their enrollees often cited problems getting access to care.We found some contracts in which people in poor health were much more likely than others to voluntarily leave the contracts' health plans. These contracts generally had lower quality scores, and their enrollees often cited problems getting access to care.
Gene L. Dodaro, Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO), today announced the appointment of two new members to the Medicare Payment Advisory Commission (MedPAC), as well as the reappointment of three current members.Gene L. Dodaro, Comptroller General of the United States and head of the U.S. Government Accountability Office (GAO), today announced the appointment of two new members to the Medicare Payment Advisory Commission (MedPAC), as well as the reappointment of three current members.
Many states conduct Medicaid demonstrations, which allow them to test new approaches for delivering Medicaid services. The Centers for Medicare & Medicaid Services monitors spending under these demonstrations to ensure that the federal government does not pay more for them than it would have paid for the state's traditional Medicaid program.Many states conduct Medicaid demonstrations, which allow them to test new approaches for delivering Medicaid services. The Centers for Medicare & Medicaid Services monitors spending under these demonstrations to ensure that the federal government does not pay more for them than it would have paid for the state's traditional Medicaid program.
A growing number of people rely on Medicaid personal care services for help with daily tasks like bathing and eating. However, these types of services are at high risk for fraud and abuse—e.g., services that were paid for but never provided.
We testified that federal and state rules for protecting Medicaid beneficiaries varied across personal care services programs. We also found that Medicaid needs better data to oversee these programs.
In 2015, state Medicaid directors earned less than most top paid executives at MCOs we reviewed. Medicaid directors’ salaries in 10 states averaged $152,439, while the total compensation for top paid executives in 15 MCOs averaged $314,278.In 2015, state Medicaid directors earned less than most top paid executives at MCOs we reviewed. Medicaid directors’ salaries in 10 states averaged $152,439, while the total compensation for top paid executives in 15 MCOs averaged $314,278.
The Centers for Medicare & Medicaid Services reviews states' efforts to reduce improper Medicaid payments, and encourages them to use collaborative audits—where CMS contractors and states work together to review the accuracy of payments made. However, some states have reported barriers (such as staff burden) to participating in collaborative audits.The Centers for Medicare & Medicaid Services reviews states' efforts to reduce improper Medicaid payments, and encourages them to use collaborative audits—where CMS contractors and states work together to review the accuracy of payments made. However, some states have reported barriers (such as staff burden) to participating in collaborative audits.
Medicare pays for some two-way video visits—referred to as "telehealth"—if the patients connect from rural health facilities. Generally, Medicare doesn’t pay for telehealth in urban facilities or in the patient's home or office.Medicare pays for some two-way video visits—referred to as "telehealth"—if the patients connect from rural health facilities. Generally, Medicare doesn’t pay for telehealth in urban facilities or in the patient's home or office.
We talked to some health care associations, who believe that telehealth has the potential to maintain or improve quality of care and said that these rules create barriers to using telehealth.
In 2016, Medicare's fee-for-service program made $41.1 billion in improper payments. To help ensure that payments are made properly, the Centers for Medicare & Medicaid Services contracts with Medicare Administrative Contractors (MACs) to educate health care providers.
Each year, over 2 million Americans get sick from bacterial infections that are resistant to antibiotics, and at least 23,000 die as a result. There has also been a steady decline in the development of new antibiotics since the 1980s—raising concerns that there may not be enough new antibiotics to replace those that have become ineffective.
Many patients who leave hospitals receive continuing care from places like rehab facilities (called post-acute care settings). When patients leave the hospitals and move to post-acute care settings, electronic health records can help providers know what the patient needs and better coordinate care.
However, we found that issues like increased costs and a lack of access to technology deter the use of electronic health records in these settings. See Report
Millions of Medicaid beneficiaries rely on personal care services for help with daily tasks like bathing and eating. However, these types of services are at high risk for fraud and abuse—e.g., services that were paid for but never provided.
We found that the Centers for Medicare & Medicaid Services needs better data to oversee these personal care services. In 2012, for example, $4.9 billion worth of these claims did not identify the person who provided the service. See Report.
States are increasingly paying for long-term care through managed care programs, paying based on set, monthly rates. How states structure these rates—aligning incentives to minimize cost and maximize service—is critical to enhancing community-based care. See Report
Although Medicaid administrators cite a key initiative to gather new, better data and improve program oversight, they haven’t developed plans to ensure the quality of these new data, or how to use them for better oversight. See Report
Medicaid is a joint federal-state health care program for low income and medically needy people, with an estimated $36 billion in improper payments in fiscal year 2016.The Centers for Medicare & Medicaid Services has taken steps to address some of these issues, but more work is needed—at both the state and federal levels.
Medicare Advantage organizations—which offer a private health plan alternative to traditional Medicare—were paid about $170 billion by the federal government and served nearly one-third of all Medicare beneficiaries in 2015. To help ensure appropriate payments, the Centers for Medicare & Medicaid Services collects data on the care and health status of Medicare Advantage enrollees.
“I remain deeply concerned about our government’s unsustainable long-term fiscal path,” said Gene Dodaro, Comptroller General of the United States and head of the GAO. “Our new report provides a frank assessment of the fiscal problems confronting the nation. Health care expenditures and net interest are now the main drivers of growing federal spending, and without policy changes, the debt-to-GDP ratio is projected to reach historic levels within 15-25 years,” he said.
To help determine how well we are meeting the needs of the Congress and the nation and maximizing our value as a leading practices agency, we assess our performance annually using a balanced set of quantitative measures. To establish targets for all of our performance measures, we examine our past performance and the external factors that could influence our future work and discuss with our senior executives what could be accomplished in the upcoming fiscal year.
In part to help its inspection efforts, FDA opened offices in China, India, Europe, and Latin America. Yet FDA has not assessed these offices' contributions to drug safety, and nearly half of their authorized positions are unfilled. We made recommendations on how FDA could improve in these areas.
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