DCMedical News: Friday, February 16, 2018
DCMedical News
Washington, D.C.
Friday, February 16, 2018
To our new readers: This is an independent newsletter, published every day that one or another House of Congress is in session. The trial subscription period will end February 28. Subscription information will be found at the bottom of these pages.
The next edition will appear Monday, February 26; Congress is in recess next week (“District Work Week”). The March schedule for publication is shown below.
THE BIG STORY TODAY IN HEALTH CARE
HHS Secretary Alex Azar unveils the Department’s plans and discusses proposed health-related expenditures in the Bipartisan Budget Act of 2018. His Thursday statement before the Committee on Energy & Commerce is found here
DOCTORS AND OTHER HEALTH PROFESSIONALS
MACRA Changes Expected: Changes are expected in the two “bonus” paths outlined for physician fees under MACRA (The Medicare Access and CHIP Reauthorization Act of 2015). Of interest, the changes appear to be coming not from the AMA or the specialty societies with which the AMA frequently coordinates federal activity. Rather, the National Physicians’ Council for Healthcare Policy, a group founded in part by House Rules Committee Chair Pete Sessions of Texas, is playing an important role. Sessions is convening meetings of the new group with members of the House Energy & Commerce Health Subcommittee, although no formal hearing has been announced.
Doctors receiving pay for Medicare work can qualify for bonus payments under MIPS (the Merit-based Incentive Payment System) or APM-A, the Alternative Payment Models (Advanced). The APM bonus is nominally higher, 5% on all Medicare Part B revenue, but in large multi-specialty groups (whose interests are primarily promoted by the American Medical Group Association) many members have qualified for higher bonuses under MIPS. MIPS bonuses accumulate, whereas the APM bonus is based on a prior year’s Part B charges and doesn’t raise baseline pay.
MedPAC (the Congressional advisory committee on the Medicare program) voted in January to recommend to Congress that significant changes be made in the MIPS track, essentially making it a voluntary program. The AMA successfully lobbied for delay in implementation of MIPS, contained in the budget law. Doctor groups with a variety of interests have expressed unhappiness with MIPS, even though “payment updates” (penalties or bonuses) have yet to begin. Sessions is quoted as saying, “We’ve tried to rip it out for a long time.”
Another subject: network adequacy? Governing magazine has a feature (found here) on the Administration’s steps to make network adequacy (number of doctors and hospitals) a state matter, even for states using the federal health insurance exchange.
Another subject: Gidwani and colleagues in the Annals of Family Medicine extol the virtues of scribes as a means of blunting physician burnout. The problem: “There is also growing evidence, however, that in their current state, EHRs are associated with decreased physician productivity and revenue, negative patient-physician interactions and relationships, and widespread physician dissatisfaction.” An excellent bibliography of practical EHR research is included. (Medscape reproduction of article, here.)
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
The proposal to allow short-term health insurance plans (Short-Term, Limited-Duration Insurance, STLDI) to provide coverage for a longer period of time will be published soon. The companion Association Health Plan (AHP) proposed rule was published in the Federal Register January 4, and is found here. The Executive Order proposing AHPs and STLDIs is found here.
Idaho is shaping up as a battleground over “less expensive” or “skimpy” health insurance. On the “less expensive” side are the Governor, a U.S. Senator and Idaho Blue Cross. On the “skimpy” argument are Democrats in Congress, advocates of Essential Health Benefits and coverage for pre-existent conditions and (at least) fifteen patient advocacy/voluntary health groups.
At Thursday’s hearing of the Finance Committee, HHS Secretary Alex Azar decided not to “weigh in” on the proposal from the State of Idaho to allow Association Health Plans, Short-Term Limited Duration Insurance plans, or other plans which have different requirements from those which would be associated with the “Essential Health Benefits” (EHBs) under the Patient Protection and Affordable Care Act (PPACA). Mr. Azar indicated he would review any plans forthcoming from Idaho, to ensure that they comply with the law. It isn’t clear that Idaho is going to apply to the federal government, however, given that Blue Cross of Idaho has already sent to the State for approval a number of plans that are not compliant with the PPACA EHBs.
Senator Wyden, questioning Mr. Azar, noted (apparently accurately) that Idaho state officials are “not planning to come to you and ask permission. They’ve made the argument that they can just do it on their own.” Idaho Blue Cross would offer the lower cost plans, at least one of which has no maternity coverage, at the same time that it offered PPACA-compliant plans on the state exchange. Idaho U.S. Senator Crapo noted that Idaho was still providing PPACA-compliant plans to those who would like to purchase them, but are allowing other options.
Fifteen patient advocacy/voluntary health groups checked in with a letter (found here) indicating that they protest the Idaho plans which would violate PPACA’s essential protections. The basic argument of the patient advocacy groups is that the supremacy clause in Article V would proscribe any Idaho actions contrary to federal law.
Here are the specific areas of contest: Denial of coverage for preexistent conditions; charging older beneficiaries as much as five times the premium charged to younger ones; imposing higher premiums on people with preexistent conditions; placing a dollar limit on insurance benefits; increasing consumer out-of-pocket costs beyond the maximum established in PPACA; and excluding Essential Health Benefit, such as maternity, newborn care and screening. The patient advocacy groups noted that providers caring for patients with what they characterized as “substandard plans” may find that their services are not covered, that medical debt grows for the patients, and that disclosure (as required in the Idaho insurance bulletin) is insufficient to educate consumers concerning the limitations of the less expensive plans.
In a separate letter (found here), Democratic leaders of the House Committees on Energy and Commerce and Ways and Means and the Senate Committees on Health, Education, Labor and Pensions (HELP) and Finance also contest the Idaho plan. Their argument is that “Consumers in so-called ‘state-based plans’ will lose access to coverage for critical services, and these plans will drive up costs for people who purchase insurance that satisfies Federal consumer protections, harming those who need health care most.”
Prior to the passage of PPACA, the contents of underwritten plans (such as those for individuals and small groups) were the purview of state departments of insurance, coordinated through the National Association of Insurance Commissioners
Meanwhile, more states are following Kentucky and Indiana to introduce work requirements into their Medicaid programs. Kentucky has discovered—consistent with the experience of managing other work-requirement programs—that it will actually spend more on Medicaid to enforce the requirements. (See a story here from the Louisville Courier Journal.) Nicole Huberfeld discusses the Kentucky program and the work requirement in NEJM, here. The major lawsuit filed against Kentucky and HHS is found here. Indiana’s waiver request with its work program is approved, here.
ASIDES
California: It’s an awkward time for Aetna’s medical director in California to have testified (in a deposition) that he never looked at patient records before turning down various authorization requests but, rather, in line with corporate policy relied on nurse reviewers who had looked at the records. Irate regulators and public figures in California have been examining their options. It recalls the landmark case in California in 1999 in which a juror found that Aetna had acted with “malice, fraud and oppression” in delaying and denying treatment to a man who died of stomach cancer while waiting for treatment authorization. At the time, Aetna’s then-chief executive Richard Huber made himself unpopular (and probably shortened his tenure) by noting that “You had a skillful ambulance-chasing lawyer, a politically motivated judge and a weeping widow.” The jury verdict was $120.5 million, the largest ever (at that time) against an HMO. Under the bus: Aetna Thursday denied that Dr. Linuma’s deposition in fact represented company policy.
“Medical Directors”: The Aetna medical director story is a familiar one in the field. Dr. Milton Packer (MedPage Today, Nov. 8, 2017, here) wrote a hilarious and sad piece about medical directors to whom he had given a luncheon talk about heart failure.
OTHER PUBLICATIONS & READINGS
CMS: Issues a final memo on “National Coverage Determination for Implantable Cardioverter Defibrillators,” found here.
EVENTS & MEETINGS
Your February & March Calendar:
February 21
11:00, at Medicare.gov, Physician Compare 90-minute webinar on PQRS.
2:00-3:30, CMS and its contractor, Acumen, LLC, host a webinar on MACRA Patient Relationship Categories and Codes, register at https://engage.vevent.com/index.jsp?eid=3523&seid=131
February 26
12:00-1:30, Alliance for Health Policy, “Using State Flexibility to Improve Medicaid Long Term Services and Supports,” Hart Building room 902, info@allhealthpolicy.org.
February 27
10:00-11:30 a.m., The Future Role of Government in Health IT and Digital Health, Bipartisan Policy Center, 1225 Eye Street NW, Suite 1000, Washington, DC 20005.
March 1
MedPAC, Ronald Reagan Building, Horizon Ballroom, 1300 Pennsylvania Ave, continuing March 2.
MACPAC, advisory body on Medicaid and the Children’s Health Insurance Program, continuing March 2.
March 6
8:00-11:00 a.m., Roll Call and CQ News present Health Care Decoded, at the Newseum, information at:
http://go.cq.com/2018HealthCareDecoded_01.RegistrationPage.html?utm_medium=newsletter&utm_source=hbmorning.
March 26
PTAC, Physician-Focused Payment Model Technical Advisory Committee, continuing March 27, information at www.regonline.com/PTACMeetingsRegistration or livestream at www.hhs.gov/live.
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).
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
DCMedical News is published every day that either the House of Representatives or the Senate is in session.
February publication dates: 26, 27, 28.
March publication dates: 1, 2, 5, 6, 7, 8, 9, 12, 13, 14, 15, 16, 19, 20, 21, 22, 23.
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com