10 Issues New CMS Administrator Will Face

Cheryl Clark, for HealthLeaders Media , April 5, 2010

This will include selecting and presiding over the launch of dozens or hundreds of quality demonstration projects—some of them probably controversial and unpopular—and translate the best ideas into pilot projects or proceed to national programs or evidence based care. This is sure to make friends, as well as enemies.

5. Work with 56 state and territorial Medicaid programs, many of which has different coverage rules, shares of payments, and eligibility criteria for 60 million beneficiaries.

6. Repel what are sure to be Congressional efforts to modify authority over certain healthcare industries, including durable medical equipment suppliers and corporations that make imaging technology.

7. Beef up efforts to find fraud, waste, and abuse, and discourage practices that lead to it.

In the last year, CMS has responded to numerous criticisms from the Office of Inspector General and the General Accountability Office that it must do a better job in handling claims and pursuing the recovery of overpayments.

8. Oversee changes to the Medicare Advantage formula, which critics charge now pays private insurers $12 billion a year more than if the beneficiaries received care under the traditional Medicare fee-for service rules.

9. Increase capacity for an estimated 15 million to 18 million more people to receive Medicaid, a special challenge because many physicians are critical of Medicaid's low fee schedules.

More doctors are declining to see new Medicaid patients and some are closing appointments for existing patients because of Medicaid's payment level. The new director has to see a way to change that course and encourage physicians to reopen their doors to Medicaid patients.

10. Strengthen and perhaps increase frequency of on-site reviews of hospitals where mistakes, avoidable hospital-acquired infections, and other conditions or quality problems have become common and severe.

Hospitals now contract to treat Medicare patients by agreeing to provide certain quality of care, and if they consistently fail to meet those agreements, CMS may threaten to end the contract, resulting in the hospital's failure to receive federal reimbursement. Some 100 U.S. hospitals are regularly threatened with loss of revenue each year, but nearly all repair the deficiencies in time.

"He's going to have to bend the cost curve while improving quality, and that's the big yawning gulf that exists right now," says Childs. "He's going to have to implement changes in the payment structure that will shift the system from paying for quantity to paying for quality."

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.

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