DCMedical News: Thursday, December 2, 2021
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Thursday, December 2, 2021
The Supreme Court and Abortion
Politico reported that “There are a handful of Supreme Court moments that are history making. This morning’s [Wednesday’s] oral arguments on Mississippi’s 15-week abortion ban seems likely to join them. A majority of justices seemed to signal they were willing to overturn Roe v. Wade, along with nearly five decades of court precedent on abortion rights.”
The Hill reported that arguments for states’ rights may prevail: “Justice Brett Kavanaugh, who along with Roberts and Justice Amy Coney Barrett is considered a key vote, seemed focused on Mississippi’s argument that abortion is a matter best left to the states. More than once Kavanaugh asked why the court is the best-suited branch of government to balance the interests of pregnant people seeking abortion against the interest of fetal life. ‘Why should this court be the arbiter rather than Congress, the state legislatures, state supreme courts, the people, being able to resolve this?’ . . . ‘And there'll be different answers in Mississippi than New York, different answers in Alabama than California, because they're two different interests at stake and the people in those states might value those interests somewhat differently.’ Many Republican officials would prefer this approach, including a dozen GOP governors who urged the justices in a friend-of-the-court brief to use the Mississippi case to eliminate federal abortion protections and let states regulate the procedure.”
On the other side, according to The Hill, “Justice Sonia Sotomayor, perhaps the court’s most outspoken liberal, minced no words in describing the repercussions if the court were to uphold Mississippi’s controversial 15-week abortion ban. She suggested the court would be perceived as highly politicized were it to overrule or seriously undermine Roe because such a decision would be viewed as merely a reflection of the court’s new lopsided 6-3 conservative majority. ‘Will this institution survive the stench that this creates in the public perception that the Constitution and its reading are just political acts?’ she asked Mississippi’s solicitor general. ‘I don't see how it is possible.’”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Patient Safety Challenges with Older Patients
A study in The American Surgeon (here) found that “Odds of preventable mortality increases with age. Perioperative venous thrombotic events, hemorrhage or hematoma, and postoperative physiologic/metabolic derangements produce significant preventable mortalities . . . Utilization of national guidelines, minimization of central venous catheter use, addressing polypharmacy especially anticoagulation, ensuring operative and procedure-based competencies, and greater incorporation of inpatient geriatricians may serve to reduce preventable mortality in elderly trauma patients.”
The study of patient safety indicators (avoidable complications that can impact outcomes) showed that “Geriatric patients have a higher mortality than younger patients with similar injuries . . . 3,452,339 geriatric patients were analyzed. Patients aged 75-84 years had 33% higher odds of preventable mortality, whereas patients aged ≥85 years had 91% higher odds of preventable mortality compared to patients aged 65-74 years.”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Surprise Billing Notices
CMS has published updated “Requirements Related to Surprise Billing: Qualifying Payment Amount, Notice and Consent, Disclosure on Patient Protections Against Balance Billing, and State Law Opt-in,” background statement found here, updated model disclosure policy here, updated model consent notice here.
CMS notes, “On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA), which included the No Surprises Act, was signed into law. The No Surprises Act provides federal protections against surprise billing and limits out-of-network cost sharing under many of the circumstances in which surprise bills arise most frequently. A surprise medical bill is an unexpected bill from a health care provider or facility that occurs when a participant, beneficiary, or enrollee receives medical services from a provider (including a provider of air ambulance services) or facility that, generally unbeknownst to the participant, beneficiary, or enrollee, is a nonparticipating provider or facility with respect to the individual’s coverage . . . Even if they go to a participating hospital or facility for emergency care, they may receive care from nonparticipating providers working at that facility. For non-emergency care, a person may choose a participating facility (and possibly even a participating provider), but not know that at least one provider involved in their care is a nonparticipating provider. In either circumstance, the person might not be in a position to choose the provider, or to ensure that the provider is a participating provider. Therefore, in addition to a bill for their cost-sharing amount, which tends to be higher for out-of-network services, the person might receive a balance bill from the nonparticipating provider or facility.”
Further, “The 2021 interim final regulations prohibit nonparticipating providers, emergency facilities, and providers of air ambulance services from balance billing participants, beneficiaries, and enrollees in certain situations unless they satisfy certain notice and consent requirements; and require health care facilities and providers to provide disclosures of federal and state patient protections against balance billing.” These are the model notice and consent provisions.
On payment amounts due, “For emergency services furnished by a nonparticipating emergency facility or provider, and for non-emergency services furnished by nonparticipating providers in a participating health care facility, an individual’s cost sharing is generally calculated as if the total amount that would have been charged for the services by a participating emergency facility or participating provider were equal to the recognized amount for such services . . . [the recognized amount] is generally the median of the contracted rates of the plan or issuer for the item or service in the geographic region.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
One Out of Five Medicaid Dollars Mis-spent, 6% of Medicare Dollars
HHS has published its annual financial report (here), indicating that federal health-care programs continue to pay billions each year in improper overpayments. Medicaid paid out nearly $98.4 billion in overpayments from July 2020 through June 2021, accounting for about 21.6% of total program reimbursements. The Children’s Health Insurance Program, or CHIP, had the highest overpayment rate at 31.8%, or $5.4 billion over the same period.
Bloomberg reports that “In recent years, the CMS has been working to cut improper payments and has found some success. For fee-for-service Medicare claims processed from July 2020 through June 2021, the improper payment rate fell to 6.26%, an all-time low. It’s the fifth straight year the improper payment rate has fallen below 10%, the compliance threshold established in the Payment Integrity Information Act of 2019. But traditional Medicare still paid out nearly $24.6 billion in overpayments, fueling a 6.15% overpayment rate for the program . . . The private Medicare Advantage plans that provide program benefits received nearly $15.2 billion in improper overpayments from 2020 to 2021. That was just over 6.7% of total program payments.”
DRUGS & DEVICES
ICER Study Analyzes Third Party Barriers to Pharmaceuticals
The Institute for Clinical and Economic Review has published a study (here) of third-party practices which create barriers for patients in accessing pharmaceutical products. The study included 28 drugs that ICER had previously determined to be cost-effective. The main takeaway is lack of transparency. In addition, third party practices unrelated to the drugs are reviewed in the study: for example, with regard to specialty drugs for which competition is not available, “Health plans explained that a ‘common approach’ for such drugs was to start them at the highest, or most expensive, tier, even if they are deemed to be fairly priced. This provides leverage to later use as an incentive to lower the price further when or if alternative drugs become available.” Other limitations on drug access have been imposed by third parties, without citation to drug labels, and without support in clinical guidelines.
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
2021 CQ Congressional Calendar here.
2022 CQ House of Representatives Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
December 6, 7, 8, 9, 10
January 10, 11, 12, 13, 18, 19, 20, 21
February 1, 2, 3, 4, 7, 8, 9, 28
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org