DCMedical News: Thursday, October 28, 2021
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Thursday, October 28, 2021
Attention Increases on Corporate and Private Equity Pressure on Providers to Commit Fraud
Kaiser pressured physicians to up-code (Bloomberg report, here). “Kaiser allegedly pressured physicians to create addenda to medical records after patient visits to add diagnoses that patients did not have or were not addressed during the in-person visit.” The Daily Poster (here) reports on resolutions of the American College of Emergency Physicians (here), “Wall Street Is Pressing ER Docs To Fleece Patients.” UnitedHealthcare sued TeamHealth (see below), alleging that actions of the latter reveal a culture of profit maximization.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Medicare Hospital at Home Waiver: Nearly 150 Hospitals Sign Up; History of the Waiver Chronicled
A brief research report (here) in the Annals of Internal Medicine analyzes results to date from hospitals enrolling early in the Medicare Hospital-at-Home (HaH) waiver. “Hospitals with waivers represented 32 states in 69 health referral regions. Most were nonprofit hospitals (79%), were minor teaching hospitals (56%), were metropolitan hospitals (92%), and had more than 299 beds (51%). Twenty three percent owned their own home health agencies.”
Background: “Hospital at home (HaH) provides acute hospital level care in a patient's home as a substitute for traditional inpatient hospital care. The HaH model has been the subject of multiple randomized controlled trials and systematic reviews and has been shown to provide safe, high-quality, patient-centered care . . . One important barrier to scaling HaH has been the lack of a payment mechanism in traditional fee-for-service Medicare. To help meet the challenges of delivering health care services in the midst of the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) issued ‘Hospitals Without Walls’ regulatory guidance that waived certain physical environment and Life Safety Code Medicare hospital conditions of participation.”
More background: “As the COVID-19 pandemic continued, on 25 November 2020, CMS announced a comprehensive strategy to enhance hospital capacity, including the Acute Hospital Care at Home (AHCaH) individual waiver. For the duration of the public health emergency, the program provides a hospital-level waiver that waives the requirement for 24/7 onsite nursing. Hospitals with waivers must follow all other conditions of participation, attest that they will be able to provide hospital-level services in patients' homes, and commit to reporting data on their program outcomes to CMS on a regular basis. Hospitals qualifying for the individual waiver receive the full hospital-level diagnosis-related group payment for services provided at home.”
Rapid uptake took place among large hospitals and major teaching hospitals but in very few rural hospitals, a program limitation. “Limited resources to launch new care models at rural hospitals or requirements for patients to be within a certain distance of the hospital may limit effectiveness in these populations . . . For-profit hospitals have similarly not yet substantially entered the scene. Barriers to uptake may include the potentially temporary nature of the AHCaH individual waiver resulting in hesitancy of hospitals and health systems to commit to HaH implementation, local resource limitations during the pandemic, state regulations, and whether private payers will follow with similar payment mechanisms.”
United Healthcare Sues TeamHealth (Again), Alleges Upcoding Fraud, Hidden Networks
Modern Healthcare (here) reports that “In addition to misrepresenting the complexity of services provided, United Healthcare says TeamHealth collected inappropriately high fees by submitting bills for services supposedly performed by doctors that actually were administered by physician assistants or nurse practitioners. TeamHealth also hid the list of medical groups it operates, making it hard for UnitedHealthcare to recognize a pattern of overbilling, according to the complaint.” United, which just reported quarterly profit of $4 billion, says TeamHealth has a culture of profit maximization.
MH reports, “TeamHealth has bought medical practices and kept them outside of insurers' provider networks. The company currently operates 3,400 emergency medical facilities that employ 18,000 providers, which accounts for 17% of the market, according to the lawsuit. Because TeamHealth pays its clinicians a flat, hourly rate, providers did not receive any [of] the extra revenue, which Blackstone retains, according to the insurer. TeamHealth's centralized billing centers are also in charge of assigning CPT codes, leaving physicians in the dark about the high rate of inflated claims.” UnitedHealthcare alleges.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Medicaid and CHIP Set PHE Service Record
More than 100 million Americans received services through the Medicaid and CHIP programs during the Public Health Emergency through February of this year. That, according to a CMS publication (here) on the program and COVID-19 services, entitled “Medicaid and CHIP and the COVID-19 Public Health Emergency Preliminary Medicaid and CHIP Data Snapshot Services through February 28, 2021.”
“From March 2020 – February 2021, over 103 million Americans, including children, pregnant women, parents, seniors, and individuals with disabilities, were enrolled across each state’s Medicaid or the Children’s Health Insurance Program (CHIP) for at least one day during the PHE period. About 42% of beneficiaries were children, which translates to about 44 million beneficiaries, and 9% of beneficiaries were over the age of 65. Approximately 55% of beneficiaries were female. 14% of the population were dually-eligible for Medicare and Medicaid. 34% of the population were white, 23% of the population were of unknown race, 20% were Hispanic, 17% were black, 4% were Asian.”
Related Story: CMS Issues Guidance Requiring Free (to Patients) Treatment for COVID-19 Under Medicaid
Bloomberg reports (here) on new CMS guidance (here, October 22) that “State Medicaid programs and the Children’s Health Insurance Program are required to cover treatments for Covid-19 without cost sharing . . . The coverage requirement includes drugs approved by the FDA for treating Covid-19, preventive therapies, specialized equipment, and treatments for post-Covid conditions, also known as ‘long Covid’ . . . States also are required to cover treatments for conditions that may complicate the treatment of Covid-19, if those conditions are otherwise covered under the state plan when a Covid-19 diagnosis is made.”
“Virtual First” Growth Continues: More Access to Primary Care, or a Higher Barrier?
Healthcare Dive reports (here) that “Cigna is also launching virtual-first health plans to select employers in 2022. The plans, which will initially be available to large, self-insured employers, include a $0 co-pay for access to MDLive primary care providers, chronic condition management and care navigation.” Also, “Last week, diversified healthcare behemoth UnitedHealth said it plans to roll out a virtual-first primary care product by the end of this year, combining its Optum physician network with payer arm UnitedHealthcare’s network offerings. Earlier this month, Teladoc made its virtual primary care pilot broadly available to commercial health plans, employers and other benefit sponsors nationwide,” soon to be joined by Amazon.
DRUGS & DEVICES
Trust Me, I’m AI; Patient-Splaining Not Necessary
A viewpoint in Lancet Digital Health (here) holds that “explainability” may not be necessary, desirable or achievable to create trust in artificial intelligence algorithms in medicine. “The black-box nature of current artificial intelligence (AI) has caused some to question whether AI must be explainable to be used in high-stakes scenarios such as medicine. It has been argued that explainable AI will engender trust with the health-care workforce, provide transparency into the AI decision making process, and potentially mitigate various kinds of bias . . . we argue that this argument represents a false hope for explainable AI and that current explainability methods are unlikely to achieve these goals for patient-level decision support . . . we advocate for rigorous internal and external validation of AI models as a more direct means of achieving the goals often associated with explainability, and we caution against having explainability be a requirement for clinically deployed models.”
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
2021 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
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