DCMedical News: Friday, May 13, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Friday, May 13, 2022
What Do We Talk About When We Talk About Quality?
Dr. Lisa Rosenbaum attempts to reimagine the health quality industry, ensnared in reimbursement-related and frequently clinically irrelevant metrics. In a three-part series in The New England Journal of Medicine (here, here and here). (Third of three parts.)
In "Peers, Professionalism, and Improvement, Reframing the Quality Question," Dr. Rosenbaum discusses intrinsic versus external motivators. In an experiment concerning reporting of cardiac surgery outcomes, "'intrinsic' response to performance information led to an improvement in outcomes nearly four times as great as that triggered by financial incentives." Kolstad, the author of that 2007 report, noted "Much of the insurance–industrial complex is built on the assumption that profit-seeking physicians will always consume excess resources unless barriers are put in their way. Formularies and prior authorizations, for example, create adversarial relationships between insurers and physicians, who may bristle at having nonphysicians dictate what’s best for their patients."
Moreover, financial rewards, based on metrics, cannot "fix" the measured results, and may make those results worse. "To the extent that financial incentives strip physicians of agency, measurement itself may play an equally pernicious role. Even Donald Berwick, who for some time bought into the mantra 'If you can’t measure it, you can’t manage it,' now recognizes the dangers of this mindset. 'That idea murders spirit. It dumbs down meaningful improvement,' Berwick said in 2019, reflecting on the evolution of his thinking about quality."
Dr. Rosenbaum concludes, "Metrics, used judiciously, still matter. But with case-based peer review, every data point becomes a story, illuminating meaningful aspects of care that measures can’t capture. Though we may not be able to extrapolate from CART [the VA program Clinical Assessment for Reporting and Tracking, used, for example, in interventional cardiology] to all of medicine, restoring some agency to clinicians has broad relevance."
She asks, "Can we build on these principles to productively reorient QI?"
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Proposed IPPS Rule for FY 2023 Published in Federal Register, Clock Begins
Arguably the most important single document in health policy each year, the "proposed rule" for the hospital Inpatient Prospective Payment System (and a variety of largely related programs) for FY 2023 was published in Tuesday's Federal Register, here. Comments are due by June 17. The final rule, published usually in late summer, would be effective October 1, 2022. (Third of a continuing series.)
Maternal health and the reduction of morbidity and mortality associated with childbirth are a new focus in the IPPS. HFMA's notes (here) that "CMS seeks to bolster maternal health through a new public-facing hospital designation. Hospitals would attain the 'Birthing Friendly' designation by attesting to maternal health best practices in quality reporting."
"The rule would set the stage for hospitals to earn a 'Birthing Friendly' designation, which would “assist consumers in choosing hospitals that have demonstrated a commitment to maternal health through implementation of best practices that advance healthcare quality, safety and equity for pregnant and postpartum patients,” according to a news release.
The designation would debut in late 2023 and would be earned by attesting 'Yes' to both questions in the Maternal Morbidity Structural Measure, which previously was finalized for adoption in the Inpatient Quality Reporting (IQR) Program. Those questions gauge whether a hospital 1) is participating in a state or national perinatal quality improvement initiative and 2) is implementing patient safety practices or bundles as part of such an initiative.
"In May, hospitals are due to report Q4 2021 data on maternity care, with initial data posted later in the year. Maternal health also is being promoted through the proposed addition of two electronic clinical quality measures to the IQR Program: Cesarean Birth and Severe Obstetric Complications. Both would be reported on a voluntary basis in 2023 and then become mandatory in 2024."
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Public Health Emergency Ending—A Possible New Emergency
Kaiser Family Foundation (KFF) reports (here) on the growth of Medicaid programs during the "Public Health Emergency" of the pandemic. The Families First Coronavirus Response Act authorized a 6.2 percentage point increase in the federal Medicaid match rate, with the dual goals of fiscal relief to states and prevention of coverage losses during the pandemic.
The statute included a requirement that Medicaid programs keep people continuously enrolled, expires at the end of the month in which the PHE ends. The current projected end of the PHE is mid-July 2022; unless that date is extended again, the "continuous enrollment requirement" will end August 1, 2022, and the enhanced FMAP will therefore conclude at the end of the quarter, September 30, 2022.
KFF estimates that Medicaid enrollment will have grown by 25% from 2019 through the end of FY 2022, 22.2 million enrollees. "Baseline growth accounts for approximately 3.5 million of the enrollment growth while the MOE continuous enrollment requirement accounts for 18.7 million. Of the total increase in enrollment (22.2 million), children accounted for an estimated 42%, expansion adults 33%, other adults 20% and the aged and people with disabilities accounted for 6%."
"Over the three-year period from FY 2020 through FY 2022, we estimate that states will have received approximately $100.4 billion in fiscal relief due to the enhanced FMAP, which is more than double the total estimated state costs due to the additional MOE enrollees ($47.2 billion). The enhanced federal matching payments — which were intended to provide states with fiscal relief — exceed the costs of the additional enrollment in every state."
The KFF report notes that "the Biden Administration has said that it will give states a 60-day notice before the PHE expires." Recently the Administration has begun to notify Governors that they should begin to plan for review and reenrollment, so that the 14 million people will not, all at once, find themselves once again without health insurance.
DRUGS & DEVICES
MA and Part D Final Rule for 2023
CMS has published in the Federal Register (here; "fact sheet," here) a final rule for Medicare Advantage and Part D drug programs for calendar year 2023. CMS says that the "final rule . . . advances CMS' strategic vision of expanding access to affordable healthcare and improving health equity in Medicare Advantage (MA) and Part D through lower out-of-pocket prescription drug costs and improved consumer protections."
Further, CMS notes that "An increasing number of Medicare beneficiaries receive services through MA and Part D plans. Over 27 million beneficiaries are enrolled in MA plans (including plans that offer Part D prescription drug coverage), and approximately 24 million beneficiaries are enrolled in standalone Part D plans."
This final rule revises the MA and Part D regulations related to marketing and communications; compliance with MA provider network adequacy requirements; quality ratings for MA and Part D plans; medical loss ratio reporting; how MA organizations calculate attainment of the maximum out-of-pocket (MOOP) limit for Parts A and B services; and the use of pharmacy price concessions to reduce beneficiary out of pocket costs for prescription drugs under Part D.
The Milbank Quarterly (here) shines a light on shortcomings in the Part D program, in coverage of new drugs, erection of barriers and tactics which, according to Milbank, interfere in the delivery of new drugs to Part D beneficiaries.
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here. The JAMA Patient Page explains the current status of oral anti-viral medications for COVID-19, here.
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
May 16, 17, 18, 19
June 7, 8, 9, 10, 13, 14, 15, 16, 21, 22, 23, 24
July 12, 13, 14, 15, 18, 19, 20, 21, 26, 27, 28, 29
August, Congress adjourned, no issues
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org