In-Home Health Risk Assessments May be Responsible for Billions in MA Overpayments, Study Finds

McKnight’s Home Care / By Adam Healy 
 
Medicare Advantage insurers may be upcoding patients’ risk scores during health risk assessments (HRAs) — and collecting billions of dollars in payments as a result of this practice, according to a new study published in HealthAffairs.
 
“There is significant concern that plans may seek to maximize risk-adjusted payment rates through the addition or escalation of diagnosis codes,” the researchers said. “Given that MA plans are responsible for the actual cost of care for their enrollees, coding efforts that increase plan payments have the potential to equip plans with additional resources that they may invest in additional or enhanced benefits … or instead, plans may retain additional payments as profits.”
 
The researchers analyzed 2019 MA encounter data for more than 4 million beneficiaries. They found that beneficiaries who received HRAs — which are typically performed in beneficiaries’ homes — were given risk scores that were almost 13% higher, on average, compared to those that did not. As a dollar amount, risk coding from HRAs could run the Centers for Medicare & Medicaid Services a bill as high as $12.3 billion annually, the study found.
 
HRAs allow insurers to capture patient information that is used to determine risk-adjusted payments. While these payments are intended to give insurers the resources to better support sicker patients, MA plans have drawn scrutiny in recent years for allegedly upcoding patients’ risk scores to increase payment rates from CMS.
 
Calls for crackdown
 
Most recently, the Better Medicare Alliance published a report in October calling for MA insurers to be more transparent about their HRA practices amid reports of upcoding. In 2020, the Department of Health and Human Services Office of Inspector General raised concerns that MA plans were abusing HRAs to reap billions of dollars in overpayments. And in 2015, the Medicare Payment Advisory Commission found that risk scores among MA beneficiaries were about 8% higher, on average, than traditional Medicare enrollees. 
 
About 44% of community-dwelling MA beneficiaries had received at least one HRA in the prior year, according to the HealthAffairs study. But despite HRAs’ widespread use, the researchers found little connection to their impact on patients’ care quality or health outcomes.
 
“The overuse of HRAs by some plans may lead to substantial payment distortions in the MA program if the risk score increases due to HRAs are not necessarily associated with increased resource use,” they wrote.

Vaccine Against Urinary Tract Infections in Development

Medscape / By Dominique Baudon, MD, PhD

Urinary tract infections are among the most common bacterial infections. They can be painful, require antibiotic treatments, and recur in 20%-30% of cases. With the risk for the emergence or increase of resistance to antibiotics, it is important to search for potential therapeutic alternatives to treat or prevent urinary tract infections.

The MV140 Vaccine

The MV140 vaccine is produced by the Spanish pharmaceutical company Immunotek. MV140, known as Uromune, consists of a suspension of whole heat-inactivated bacteria in glycerol, sodium chloride, an artificial pineapple flavor, and water. It includes equal percentages of strains from four bacterial species (V121 Escherichia coli, V113 Klebsiella pneumoniae, V125 Enterococcus faecalis, and V127 Proteus vulgaris). MV140 is administered sublingually by spraying two 100-µL doses daily for 3 months.

The vaccine is in phase 2-3 of development. It is available under special access programs outside of marketing authorization in 26 countries, including Spain, Portugal, the United Kingdom, Lithuania, the Netherlands, Sweden, Norway, Australia, New Zealand, and Chile. Recently, MV140 was approved in Mexico and the Dominican Republic and submitted to Health Canada for registration.

A randomized study published in 2022 showed the vaccine's efficacy in preventing urinary tract infections over 9 months. In total, 240 women with a urinary tract infection received MV140 for either 3 or 6 months or a placebo for 6 months. The primary outcome was the number of urinary tract infection episodes during the 9-month study period after vaccination.

In this pivotal study, MV140 administration for 3 and 6 months was associated with a significant reduction in the median number of urinary tract infection episodes, from 3.0 to 0.0 compared with the placebo during the 9-month efficacy period. The median time to the first urinary tract infection after 3 months of treatment was 275.0 days in the MV140 groups compared with 48.0 days in the placebo group.

Nine-Year Follow-Up

On April 6 at the 2024 congress of The European Association of Urology, urologists from the Royal Berkshire NHS Foundation Trust presented the results of a study evaluating the MV140 vaccine spray for long-term prevention of bacterial urinary tract infections.

This was a prospective cohort study involving 89 participants (72 women and 17 men) older than 18 years with recurrent urinary tract infections who received a course of MV140 for 3 months. Participants had no urinary tract infection when offered the vaccine and had no other urinary abnormalities (such as tumors, stones, or kidney infections).

Postvaccination follow-up was conducted over a 9-year period, during which researchers analyzed the data from the electronic health records of their initial cohort. They queried participants about the occurrence of urinary tract infections since receiving the vaccine and about potential related side effects. Thus, the results were self-reported…

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Draft OASIS E-1 Manual and Instruments

The draft Guidance Manual for the OASIS-E1 version of the OASIS data set, effective January 1, 2025, is available in the Downloads section of the OASIS User Manuals | CMS page, www.cms.gov/medicare/quality/home-health/.... The draft OASIS-E1 Instruments (All Items and Time Points versions) are available in a zip file in the Downloads section of the OASIS Data Sets | CMS page. 

Why is Cancer Called Cancer? We Need to go Back to Greco-Roman Times for the Answer

The Conversation / By Konstantine Panegyres

One of the earliest descriptions of someone with cancer comes from the fourth century BC. Satyrus, tyrant of the city of Heracleia on the Black Sea, developed a cancer between his groin and scrotum. As the cancer spread, Satyrus had ever greater pains. He was unable to sleep and had convulsions.

Advanced cancers in that part of the body were regarded as inoperable, and there were no drugs strong enough to alleviate the agony. So doctors could do nothing. Eventually, the cancer took Satyrus' life at the age of 65.

Cancer was already well known in this period. A text written in the late fifth or early fourth century BC, called Diseases of Women, described how breast cancer develops:

"Hard growths form […] out of them hidden cancers develop […] pains shoot up from the patients' breasts to their throats, and around their shoulder blades […] such patients become thin through their whole body […] breathing decreases, the sense of smell is lost […]"

Other medical works of this period describe different sorts of cancers. A woman from the Greek city of Abdera died from a cancer of the chest; a man with throat cancer survived after his doctor burned away the tumor.

Where does the word 'cancer' come from?

The word cancer comes from the same era. In the late fifth and early fourth century BC, doctors were using the word karkinos—the ancient Greek word for crab—to describe malignant tumors. Later, when Latin-speaking doctors described the same disease, they used the Latin word for crab: cancer. So, the name stuck.

Even in ancient times, people wondered why doctors named the disease after an animal. One explanation was the crab is an aggressive animal, just as cancer can be an aggressive disease; another explanation was the crab can grip one part of a person's body with its claws and be difficult to remove, just as cancer can be difficult to remove once it has developed. Others thought it was because of the appearance of the tumor.

The physician Galen (129–216 AD) described breast cancer in his work A Method of Medicine to Glaucon, and compared the form of the tumor to the form of a crab:

"We have often seen in the breasts a tumor exactly like a crab. Just as that animal has feet on either side of its body, so too in this disease the veins of the unnatural swelling are stretched out on either side, creating a form similar to a crab."…

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