DCMedical News: Monday, January 10, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Monday, January 10, 2022
Congress Returns
The second session of the 117th Congress begins today. A letter from Majority Leader Hoyer to Democratic Members of the House (here) lays out an agenda for January and February. Hoyer notes, “The House remains prepared to act on President Biden’s agenda to ensure our nation can Build Back Better from the COVID-19 pandemic.”
New Hospital Requirements; Guidelines for Hospital Prices and Estimates
“January 1 brought new responsibilities for U.S. hospitals to publish payment information, provide a notice of the availability of such information, and make Good Faith Efforts (GFE) to provide estimates of total payments due from patients for shoppable services. Notice and Consent must be given by providers or facilities furnishing out of network services to patients post stabilization or for non-emergent services in the timeframe outlined. Also, the new transparency and surprise billing laws include prohibitions on balance billing for certain items and services.” Coverage in The New York Times, here. The Wall Street Journal finds (here) that hospitals—including many of the largest, and chains historically affiliated with the Catholic church--are still lagging in compliance with the new rules.
Hospitals Stretched, Some Overwhelmed, in U.S. COVID-19 Pandemic
A typical Google survey (here) of American hospitals this week shows all to be stretched in the availability of beds and staff, and some overwhelmed, unable to care for many of the non-COVID patients otherwise presenting. The Washington Post reports that nursing home staff shortages (here) prevent hospitals from transferring patients.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Mobile Stroke Units Improve Care
A summary of recent studies of mobile stroke units (MSUs) in the NEJM Journal Watch (here) found “Stroke patients treated in MSUs underwent thrombolysis sooner and had better outcomes than patients treated at hospitals” and “strategic deployment of MSUs in areas where people aren't reasonably close to certified stroke centers could be a game-changer in stroke care.”
United, Like Anthem Earlier in 2021, Pulls Back from ED Appropriateness Review
Healthcare Dive reports (here) that UnitedHealthcare has “clarified” that it no longer intends to retroactively deny hospital emergency room claims. “Previously, the coverage determination appeared to suggest UnitedHealthcare would begin on Jan. 1 to review claims for emergency services to evaluate whether the patients' medical needs required ER care . . . if the payer determined ER-level care wasn't warranted, it might retroactively elect to deny the claim. UnitedHealthcare first attempted to implement the controversial policy last summer but delayed it in June following fierce backlash from provider groups and patient advocates . . . saying it would require patients with likely little-to-no medical experience to determine the severity of their injuries and illnesses, put patients on the hook for potentially exorbitant ER bills and eventually threaten provider finances due to the loss of reimbursement. The payer originally cast the delay as only a temporary pause, at least until the end of the national public health emergency for COVID-19. However, UnitedHealthcare confirmed . . . on Monday that it has no intent of moving forward with the stricter coverage criteria.” AHA letter of concern, here.
Hospital People Profiled in The New Yorker
This week’s edition of The New Yorker attempts to capture the “story” of hospitals and the pandemic. From editor David Remnick’s introduction, “Omicron is not causing as much intense illness as other covid variants, but it is so transmissible that the countless cases being registered every day have placed a terrible strain on hospitals, doctors, and nurses all the same . . . In “A Doctor’s Dark Year,” Dhruv Khullar profiles a trauma surgeon in Boston as she reflects on the most challenging and emotionally taxing period she has ever faced. In “The First Face You See at a South Bronx Hospital,” Zach Helfand writes about Maria Lopez, a hospital staffer who volunteered to greet (and console) patients in the busiest E.R. in the South Bronx. (“The hardest part of the job, Lopez said, is knowing that patients are alone.”) In “A Bellevue Doctor’s Pandemic Diary,” Danielle Ofri chronicles her formidable efforts during the unsettling early weeks and months after the pandemic descended on New York City. In “Texts from My Father, in Elmhurst Hospital,” Victor Zapana, Jr., describes how he communicated with his father, a Peruvian immigrant and war veteran, after he came down with COVID-19 and was hospitalized in Queens. Finally, in “How to Hope: Lessons from a Children’s Hospital,” Chris Adrian recounts his experiences as a pediatric palliative-care doctor in Los Angeles.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Proposed Rule for Part D, MA Plans
The American Health Law Association reports that, “The Centers for Medicare & Medicaid Services (CMS) issued [link to CMS newsroom] January 6 a proposed rule [360 pgs., to be published in this Wednesday’s Federal Register] aimed at reducing Medicare beneficiaries’ out-of-pocket costs under Part D, and improving consumer protections and health equity in the Medicare Advantage (MA) and Part D programs.”
CMS noted that Part D plans and pharmacies are entering into payment arrangements where plans pay less to pharmacies if the pharmacies do not meet certain criteria. However, those price concessions are not disclosed to beneficiaries at the point of sale. The proposed rule would have beneficiaries also share in the savings, according to a fact sheet. The proposal would take effect next January 1, 2023.
In addition, the proposed rule looks to strengthen patient protection under MA and Part D programs, by (1) cracking down on deceptive marketing tactics to enroll beneficiaries in MA and Part D plans; (2) expanding the reasons for denying a new contract or service area expansion of an existing MA contract; (3) proposing to require plan applicants to demonstrate compliance with network adequacy standards before the agency will approve a new or expanded MA plan; (4) holding MA plans more accountable for amounts used to provide supplemental benefits (e.g., dental, vision, hearing, transportation, meals) and the percent of plan revenue spent on patient care and quality improvement activities (the “Medical Loss” Ratio).
Comments on the proposed rule are due March 7.
Proposed Rule for Marketplace Plans in 2023
Also from AHLA, “The Department of Health and Human Services (HHS) issued [link to HHS news release] December 28, 2021 a proposed rule (87 Fed. Reg. 584) [145 pgs., Federal Register, January 5] to update parameters for health insurance issuers offering coverage on the Affordable Care Act (ACA) marketplaces for the 2023 plan year that includes provisions aimed at making it easier for consumers to comparison shop.”
“The proposed rule would require all issuers in the federally facilitated marketplace (FFM) and state-based marketplaces on the HealthCare.gov platform to offer standardized plan options, which have uniform cost-sharing structures that help consumers make plan comparisons and can improve competition . . . Issuers must offer standardized plan options for every product network type, metal type, and plan classification, HHS said.”
The AHLA report noted that CMS is proposing to restart federal network adequacy reviews, highlighting time and distance to care, and appointment wait times, and also requiring issuers to include 35% of available essential community providers in their networks, up from 20% currently, according to a CMS fact sheet.
Comments on the proposed rule are due January 27.
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
January 11, 12, 13, 18, 19, 20, 21
February 1, 2, 3, 4, 7, 8, 9, 28
March 1, 2, 3, 7, 8, 9, 10, 15, 16, 17, 18, 28, 29, 30, 31
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org