DCMedical News: January 30, 2018
DCMedical News
Washington, D.C.
Tuesday, January 30, 2018
THE BIG STORY TODAY IN HEALTH CARE
State of the Union (tonight, 9:00 p.m. EST):
Polls show Americans want to hear about the President’s plans for health care. But these words from Commonwealth President Dr. David Blumenthal (here) are sobering for any further positive health initiatives in 2018: “Health care reform is complicated and politically fraught. Presidents and their allies undertake it at their peril, but if they are committed to major health care change, they can succeed only when the president’s political capital is at its height: during the first months of their first year in office . . . Having failed to repeal and replace the ACA in his inaugural year, the President and his party are now grappling with the reality that their time for dramatic health reform has likely passed. They can and will whittle away at coverage through executive maneuver — particularly via state Medicaid waivers intended to discourage enrollment. But the difficult legislative action required to rip the ACA out root and branch no longer seems tenable . . . If history is any guide, they will not return to wholesale revisions of the ACA until the President’s next term, if he has one, and even then, success is unlikely.”
Next Continuing Resolution deadline: February 8.
DOCTORS AND OTHER HEALTH PROFESSIONALS
Representatives of 75 medical and health professional organizations sent a letter (here) to Congressional leaders, noting the potential damage to their patients from delay in funding of multiple health programs. They wrote, “This lapse in authorization and funding, coupled with the continuous enactment of short-term patches, has put in jeopardy health care services for seniors on Medicare and patients in underserved communities, resources for health care providers in rural communities, and programs aimed at training primary care physicians. Among the programs that have been allowed to lapse or are awaiting reauthorization and funding are: • Community Health Center Fund • Medicaid Disproportionate Share Hospital payment funding • Medicare Therapy Cap Extension • Teaching Health Center Graduate Medical Education Program • Maternal Infant and Early Childhood Home Visiting Program • National Health Service Corps • Physician Fee Schedule GPCI Parity Policy.”
One example: CMS is now sending out notices for speech, occupational and physical therapy bills which were held against hope that reimbursement “therapy caps” would be lifted.
A bit of a mess in single-payer world: this week’s British Medical Journal reported litigation involving back office shambles secondary to privatization (here), threats of litigation over the introduction of Accountable Care Organizations into the UK (here) and (gasp) news that GPs will not in fact be “struck off” for prescribing Genentech’s Avastin (at a much lower cost than Novartis’ Lucentis) for wet, age-related macular degeneration (here). This last is a new type of pharma initiative: “A group of 12 CCGs [Clinical Commissioning Groups] in northeast England and Cumbria face judicial review brought by Bayer and Novartis against their policy to offer patients a choice of drug to treat wet AMD, including bevacizumab [generic name for Avastin].” Just like home!
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
The CMS “Community Engagement” letter from CMS to state Medicaid Directors (found here). Says CMS in the letter, “The policy responds to numerous state requests to test programs through Medicaid demonstration projects under which work or participation in other community engagement activities - including skills training, education, job search, volunteering or caregiving - would be a condition for Medicaid eligibility for able-bodied, working-age adults.” Thus far, CMS has received demonstration project proposals along the lines of this invitation from 10 states, Arizona, Arkansas, Indiana, Kansas, Kentucky, Maine, New Hampshire, North Carolina, Utah and Wisconsin. An FAQ from CMS is found here.
Suit was filed January 24 against CMS (found here) for approving such a waiver for Kentucky, contending that “This case challenges the efforts of the Executive Branch to bypass the legislative process and act unilaterally to ‘comprehensively transform’ Medicaid, the cornerstone of the social safety net. Purporting to invoke a narrow statutory waiver authority that allows experimental projects ‘likely to assist in promoting the objectives’ of Medicaid, the Executive Branch has instead effectively rewritten the statute, bypassing congressional restrictions, overturning a half century of administrative practice, and threatening irreparable harm to the health and welfare of the poorest and most vulnerable in our country.”
More litigation: New York and Minnesota (the only two states to have established a “Basic Health Program” (BHP) under the Patient Protection and Affordable Care Act) sued HHS (on June 26, Complaint found here) for unilaterally reducing federal funding for each state’s Basic Health Program, in contravention of HHS’ responsibility to make BHP payments. This suit also alleges violation of the Administrative Procedures Act, with its notice-and-comment rulemaking process. The BHP was an alternative to marketplace coverage for uninsured individuals having incomes between 133 and 200 percent of the federal poverty level. BHP was an alternative thought more affordable for people in this income bracket, even though, under other provisions of PPACA, they would qualify for premium tax credits and cost-sharing reductions used to purchase a marketplace plan and make co-payments for services. Only New York and Minnesota created such plans, but total enrollment is over 800,000. Premiums are capped at $20 per month in New York and $80 per month in Minnesota. The state used federal funds to subsidize those rates.
HOSPITALS AND HEALTH CARE FACILITIES
Rural hospital remedies: the Bipartisan Policy Center held a program entitled “Reinventing Rural Health Care: A Case Study of Seven Upper Midwest States,” study found here. The group studied rural health care in seven states, Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota, and Wyoming. The group’s recommendations (you’re your editor’s comments in italics):
“Rightsizing Health Care Services to Fit Community Needs: Not every rural community needs to have a Critical Access Hospital; communities should tailor available services to the needs of the community, which for many rural areas are driven by changing demographics.”
Critical Access Hospitals began as an antidote to DRGs, the 1983ff “prix fixe” of hospital reimbursement which put a premium on “throughput” and payment per case, versus cost-based payment per day of care. The Montana Hospital Association worked with the then-junior Senator Max Baucus to develop the CAH alternative, payment based on cost (as in the original Medicare plan). Senator Baucus, later Chair of the Finance Committee, oversaw the CAH universe as it grew to (today) more than 1,300 of the nation’s 4,950 acute general hospitals. CAHs were limited to 25 beds, but could have adjacent skilled nursing facility “swing” beds for higher occupancy. (This latter provision is now under CMS attack.)
“Creating Rural Funding Mechanisms: Once the right system and services have been identified for a community, funding mechanisms and payment models should reflect the specific challenges that rural areas face - such as small population.”
This is about as specific as the report gets concerning money.
“Building and Supporting the Primary Care Physician Workforce: With the appropriate services and funding, rural communities can build sustainable and diverse workforces.”
Ditto, nothing specific, nothing about graduate medical education, nothing about immigration.
“Expanding Telemedicine Services: Health professionals working in rural areas need the right tools for success.”
Polls show that patients, in general, want doctors, not screens.
Legislation proposed by the group: “The Save Rural Hospitals Act proposes providing financial relief to rural hospitals by eliminating the Medicare sequester for rural hospitals and by providing a permanent extension of rural and super-rural ambulance payments, as well as by establishing a new designation for rural hospitals that allows them to transform into outpatient-care hospitals.”
The importance of the sequester (withhold of 2% of Medicare payment to all hospitals) appears again. Transformation of hospitals into outpatient facilities ignores (a) the role of the hospital in attracting specialist physicians, many of whom have little to do in low volume outpatient areas, (b) the role of the hospital as an “active organizing principle” to bring physicians to communities, and to vet them, and (c) the desire of rural communities to have full service hospitals.
EVENTS & MEETINGS
Your January & February Calendar:
January 31: 10:00 a.m. to 11:30, Bipartisan Policy Center https://bipartisanpolicy.org/events/, Policy Roadmap for Individuals With Complex Care Needs (stars, including Burke, Feder, Mann)
February 1: 9:00 a.m. Health Affairs, kick-off for cost control series
February 5: 8:30 a.m., Academy Health holds its National Health Policy Conference at the Marriott Marquis, Washington, D.C. See web site (https://academyhealth.confex.com). Continues through February 6. Cost to attend $1,315.
OTHER PUBLICATIONS
Avalere studies 340B (found here), concludes most hospitals will be better off under the new rules. Discussion tomorrow.
New York Times: Dr. Aaron Carroll, a pediatrician and health policy wonk, reveals that preventive care doesn’t save money (article here).
For reference:
Members of the Senate (here) and Members of Senate Committees (here), Senate Calendar (here).
Members of the House with their House Committees (here), House Calendar (here).
DCMN: Publication dates for the remainder of January: 31. February publication dates: 5, 6, 7, 8, 9, 12, 13, 14, 15, 16, 26, 27, 28. Past issues may be accessed as follows: at the top of this e-mail, click on “View this email in your browser,” then click on “Past Issues.”
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Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com