Fiscal sustainability presents a national challenge shared by all levels of government. GAO’s simulations of long-term fiscal trends in the state and local government sector—published since 2007—have consistently shown that state and local governments face long-term fiscal pressures driven largely by the rising health-related costs of Medicaid and the costs of health care compensation for employees and retirees.
Nursing Home Compare is an online tool that allows people to research and compare nursing homes using a rating system. We found that most people think the site is helpful, but it's not perfect. For example, it lacks some key information, such as consumer satisfaction scores.
We found that FDA and some states collect data on the number of drug compounders, but not the volume of compounded drugs. Notably, nearly all of the states we surveyed reported having drug compounding laws or policies for pharmacists, but not for physicians. Additionally, some states reported challenges with their communication with FDA.
Screening doctors and other providers to make sure they are legitimate helps. In 2011 Medicare strengthened its screening process—for example, by visiting more doctors' offices to verify information and conducting more background checks. As a result, over 700,000 medical providers lost their Medicare billing privileges, saving an estimated $2.4 billion.
Preventing the use of illicit drugs (which includes the misuse of prescription drugs) is less expensive than treating addiction. We convened a diverse panel of education, health care, and law enforcement experts on June 22, 2016, to discuss strategies to prevent this drug use.
To help make the upcoming presidential and congressional transitions as informed as possible, the U.S. Government Accountability Office (GAO) has launched a new mobile app that provides users easy access to the watchdog agency’s priority recommendations for improving government operations.
Overdoses of opioids such as heroin caused more than 28,000 deaths in the U.S. in 2014. Medication-assisted treatment (which combines medication with behavioral therapy) can reduce opioid addiction. We looked at factors that can affect patients' access to medication-assisted treatment.
While the Department of Health and Human Services is working to better align its health care quality measures across programs and private payers, OIG recommends that it set key priorities for these efforts and develop more meaningful measures.
GAO found that, for each fiscal year from 2011 through 2014, direct and indirect care costs were lower as a percentage of revenue, on average, at for-profit SNFs compared with nonprofit and government SNFs. Direct and indirect care costs were similarly lower at chain SNFs compared with independent SNFs. In addition, the median margin, which measures revenue relative to costs, was higher for for-profit and chain SNFs than for other SNFs in each of the 4 years.
Millions of Medicaid beneficiaries are in fee-for-service arrangements, in which states pay health care providers per service—if those providers participate in Medicaid. We looked at the resources available to help beneficiaries find participating health care providers.
HHS has established an oversight program for compliance with privacy and security regulations, but actions did not always fully verify that the regulations were implemented. Specifically, HHS's Office of Civil Rights investigates complaints of security or privacy violations, almost 18,000 of which were received in 2014.
The overall goal of the forum's discussions and of this report is to help lay the groundwork for future efforts to maximize DAI benefits and minimize potential drawbacks. As such, the forum was not directed toward identifying a specific set of policies relevant to DAI. However, participants suggested that efforts to help realize the promise of DAI opportunities would be directed toward improving data access, assessing the validity of new data and models, creating a welcoming DAI ecosystem, and more generally, raising awareness of DAI’s potential among both policymakers and the general public.
Federal data show that direct care workers who provide LTSS numbered an estimated 3.27 million in 2014, or 20.8 percent of the nation's health workforce. Federal data show that wages for direct care workers, while differing by occupation, are generally low, averaging between approximately $10 and $13 per hour in 2015. However it is unclear to what extent these wage data include direct care workers employed directly by the individuals for whom they care. The number of these workers, often referred to as independent providers, is believed to be significant and growing.
GAO's review of concentration in the private health-insurance market found that enrollment was concentrated among a small number of health insurance companies (issuers) in most states in 2014, including in the newly established exchanges. On average, in each state and the District of Columbia, 11 or more issuers participated in each of three types of markets—individual, small-group, and large-group—from 2011 through 2014.
As previously reported for the 2014 and 2015 coverage years, GAO's undercover testing for the 2016 coverage year found that the health-care marketplaces' eligibility determination and enrollment processes remain vulnerable to fraud. The marketplaces initially approved coverage and subsidies for GAO's 15 fictitious applications. However, three applicants were unable to put their policies in force because their initial payments were not successfully processed. GAO focused its testing on the remaining 12 applications.
To varying degrees, QHP enrollees expressed satisfaction with specific aspects of their plan, including their coverage and choice of providers, and plan affordability. Stakeholders—including experts, state departments of insurance, and others GAO interviewed—and literature GAO reviewed also revealed some concerns about QHP enrollee experiences.
Manufacturers reported that competition, determined by the price and availability of the same drug from other manufacturers, is the primary driver of generic drug prices, as less competition could drive prices higher. Stakeholders noted that the level of competition in the generic drug market is influenced by a variety of factors, including raw material shortages, production difficulties, consolidation among manufacturers, and a backlog of new generic drug applications awaiting federal review.
GAO's undercover testing for the 2015 coverage year found that the health-care marketplace eligibility determination and enrollment process for qualified health plans—that is, coverage obtained from private insurers—remains vulnerable to fraud.
Medicaid has been the focus of proposals to limit the federal expenditure commitment. One such approach, referred to as a per capita cap, would limit the amount of federal Medicaid funding states could receive per enrollee, adjusting the federal expenditure commitment based on the population covered. Whether to change the financing of the Medicaid program is a decision requiring congressional action. GAO was asked to examine considerations for designing a method to reimburse states on a per capita basis for individuals enrolled in Medicaid.
In nearly all states, the number of issuers participating in individual markets decreased from 2013 to 2014, while fewer states' small group and large group markets had decreased participation. However, across the three markets, those issuers exiting each state market before 2014 generally had less than 1 percent of the market in the prior year. There were also issuers that newly entered state markets in 2014.
GAO was asked to compare Medicare’s payments for Part B drugs with those of other payers. In this report GAO provides information on the payment methodologies, drug utilization management strategies, and cost-containment approaches for physician-administered drugs that are used by Medicare, Medicaid, VA, and private payers.
Use of drug coupons in the private sector has increased in recent years. GAO was asked to study coupon programs for drugs covered by Medicare Part B, including any implications for Part B spending.
Drug shortages are a serious public health concern. GAO previously found that many shortages were of sterile injectable drugs and could generally be traced to supply disruptions caused by manufacturers slowing or halting production to address quality issues.
PPACA established section 1332 waivers to allow for state innovation in providing health insurance under PPACA. Under section 1332, states may seek federal approval to waive certain PPACA requirements, including requirements related to health insurance exchanges. HHS and Treasury share responsibility for reviewing and approving 1332 waivers. To receive approval, states are required to meet statutory criteria that the waiver provides coverage to at least a comparable number of state residents as would have received coverage without the waiver, that the coverage is at least as comprehensive and affordable as it would be in the absence of the waiver, and that the waiver will not increase the federal deficit. GAO was asked to examine the status of the Departments’ implementation of the review and approval process for section 1332 waivers.
Medicare Part B covers drugs typically administered by a physician. Medicare pays physicians and other providers for these drugs at an amount generally equal to the ASP of the drug plus a fixed percentage. These payment rates are calculated quarterly by CMS based on price and volume data reported by drug manufacturers. Members of Congress and others have questioned the amount that both Medicare and its beneficiaries spend on Part B drugs.
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