DCMedical News: Friday, October 1, 2021
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Friday, October 1, 2021
Pandemic Toll Improves, Mandates Appear to Work, But Data Is Confusing and Unreliable
New cases, deaths and hospitalizations appear to be leveling off, with the exception of pockets of large numbers of unvaccinated persons. Mandates improve vaccination rates, reports The New York Times (here). “Until now, the biggest unknown about mandating Covid vaccines in workplaces has been whether such requirements would lead to compliance or to significant departures by workers unwilling to get shots — at a time when many places were already facing staffing shortages. So far, a number of early mandates show few indications of large-scale resistance.”
“Mandates are becoming more commonplace as several other states have imposed requirements for workers. In New York, Rhode Island, Maine, Oregon and the District of Columbia, health care workers must get vaccinated to remain employed. In New Jersey, Pennsylvania, Maryland and Illinois, health workers have the option to be tested regularly if they choose not to get inoculated.”
What we know about the epidemiology of Coronavirus infections, on the other hand, is that data is often sketchy and unreliable. The Washington Post reports (here) that “The contentious and confusing debate in recent weeks over coronavirus booster shots has exposed a fundamental weakness in the United States’ ability to respond to a public health crisis: The data is a mess.”
“How many people have been infected at this point? No one knows for sure, in part because of insufficient testing and incomplete reporting. How many fully vaccinated people have had breakthrough infections? The Centers for Disease Control and Prevention decided to track only a fraction of them. When do inoculated people need booster shots? American officials trying to answer that have had to rely heavily on data from abroad. Critically important data on vaccinations, infections, hospitalizations and deaths is scattered among local health departments, is often out of date and hard to aggregate at the national level, and it is simply inadequate for the job of battling a highly transmissible and stealthy pathogen.”
“The dearth of timely, comprehensive data impaired the ability of the nation’s top public health officials and infectious-disease experts to reach a consensus on the need for booster shots. The experts looked at conflicting data from Israel, Britain and the United States and came up with a bewildering set of recommendations. The debate seemed to confuse more than clarify arguments for the necessity of an additional shot.”
DOCTORS, NURSES AND OTHER HEALTH CARE PROFESSIONALS
Surprise Bill Interim Rule #3
CQ reports (here) that “The Biden administration issued an interim final rule Thursday [here, 521 pgs.] to implement a surprise medical billing law, detailing how payment disputes between health insurance plans and medical providers would be resolved,” the third rule proposed to date on implementing the statute, effective January 1. Thursday’s rule sets up the independent dispute resolution process that will determine how much insurers would owe providers such as doctors if the two parties cannot reach an agreement on their own in most cases when a patient receives a surprise medical bill . . . Beginning next year, under the rule, a patient's health plan and provider would have 30 days to negotiate payment, while the patient's costs would be limited to a copay.”
“After the 30-day open negotiation period, either party could initiate the federal dispute resolution process. The two parties would jointly select an arbiter, who would be certified by the federal government . . . Both parties would then submit their proposed payment rate with supporting documents to the arbiter. The certified independent dispute resolution arbiter would select one of the amounts as the out-of-network payment rate that would be owed.”
“The arbiter would base their decision on the qualifying payment amount, typically an insurance plan’s median contracted rate for a given geographic area. The interim final rule dictates that an arbiter would choose the amount closest to that unless they determine that amount is significantly different from the appropriate out-of-network rate. The interim final rule would also require providers to provide a good-faith cost estimate to uninsured people or people who are choosing to see a doctor outside of their insurance network ahead of any planned services.”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Will Walmart Follow Haven, Amazon and Google?
Business Insider (here) reports that “Walmart's health clinics are struggling with basic functions like billing, imperiling the company's push to upend care.” The report says “It's been two years since Walmart opened its first primary-care clinic in rural Dallas, Georgia . . . Since then, the company has opened 20 clinics, mostly in Georgia, and it's now gearing up to enter Florida. More than 230,000 patients have visited the clinics. But the retail giant is still struggling to master basic healthcare operations. Prices aren't as low or clear-cut as they appear, thanks in part to hidden fees, and problems with billing patients and insurers have gotten in the way of Walmart Health's ability to improve healthcare for patients.” Walmart had previous efforts in health care, in 2007 and 2014, “neither of which lived up to the company’s ambitions.”
AHA Report Shows Average “Community Benefit” of Tax-Exempt Hospitals to be 13.9% of Expenses
AHA released its 2020 report on community benefit (here), based on analysis of Schedule H from Form 990 returns from tax exempt hospitals. “AHA identified 2,791 total hospitals in the Schedule H data file and matched these records with the AHA Annual Survey database.” The average of 13.9% of expenses includes “unreimbursed Medicaid” and “Medicare shortfall,” measures of the difference between reimbursement from those payers and hospital-calculated “costs.”
New York Governor’s Executive Order Included Hospital Industry “Wish List” Items
Bill Hammond, of The Empire Center, reports (here) that the Executive Order of New York Governor Hochul meant to augment hospital staffing (see DCMN 9-30) included items requested by the hospital industry which would hamper the ability of health insurers to question hospital bills. “Buried in Governor Hochul’s emergency order on health-care staffing is a temporary bar against insurance companies challenging claims submitted by hospitals–and an influential hospital association is taking credit . . . Hochul suspended insurers’ ability to question hospital bills before paying them–including pre-authorization of scheduled surgeries and retrospective review of services already provided--in the name of freeing hospitals’ administrative staff for other duties.” Hammond notes that the Greater New York Hospital Association (GNYHA) claimed credit for the provision in a memo to members, as it did in other State actions: “This week’s memo from GNYHA was reminiscent of an episode in the spring of 2020, when the organization successfully lobbied to limit lawsuits against hospitals related to the coronavirus pandemic.” It also recalled Hammond’s work in exposing the March 25, 2020 directive from the NY Department of Health, instructing nursing homes to take back coronavirus patients from hospitals, which helped lead to the underreporting of virus deaths.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Uninsured Unaware of Affordable Health Insurance Options
The Urban Institute (here) reports that “Subsidized health insurance available through federal or state-based Marketplaces can provide an affordable coverage option, including for those who have lost employer-sponsored insurance due to the pandemic.” In its surveys, however, “Fewer than half (48.2 percent) of nonelderly adults uninsured in April 2021 reported having heard a lot or some about the Marketplaces, and fewer than a third (32.2 percent) reported having heard a lot or some about subsidies; the remainder of both groups had heard only a little or nothing at all.”
READINGS & REFERENCES
Massachusetts Health Policy Commission 2021 Annual Health Care Cost Trends Report
The report (here) notes that “Spending on services in hospital outpatient departments was the fastest-growing service category for the Massachusetts commercial market in 2019, where per enrollee spending grew 7.6 percent. Spending on physician and other professionals . . . increase[ed] 6.1 percent in 2019.”
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
2021 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
October 19, 20, 21, 22, 25, 26, 27, 28
November 1, 2, 3, 4, 5, 15, 16, 17, 18, 30
December 1, 2, 3, 6, 7, 8, 9, 10
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org