DCMedical News: Wednesday, May 18, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, May 18, 2022
Cardiac Care Disrupted Due to Changing Practice, Scientific Disagreement, Pandemic Stress
TAVI Extended to Patients With Lower Operative Risk
A new report in JAMA (here) finds non-invasive aortic valve replacement a good substitute for surgical value repair in patients with lower risk and co-morbidities. "Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical aortic valve replacement for patients with severe, symptomatic aortic stenosis requiring intervention. The first clinical use of TAVI was in 2002 and evidence from randomized clinical trials has supported its adoption as the treatment of choice for patients who are unfit for conventional surgery or who are at high operative risk. Early trials used first-generation TAVI devices, which were associated with a high rate of procedural complications. Technological developments, procedural refinements, and increased operator experience have subsequently resulted in improved outcomes, and there is increasing interest in the use of TAVI in patients at lower operative risk."
The study: "In this randomized clinical trial that included 913 patients at moderately increased operative risk due to age or comorbidity, all-cause mortality at 1 year was 4.6% with TAVI vs 6.6% with surgery," meaning that "more moderately ill patients were good candidates for the less invasive procedure."
PCI, CABG or Medical Therapy for Moderate to Severe Ischemic Heart Disease
Revascularization, PCI or medical treatment for stable moderate to severe ischemic heart disease is again on the front page. In this report from Medscape, discussing research differences aired in Circulation, "As previously reported, the main ISCHEMIA findings showed no significant benefit for an initial strategy of percutaneous coronary intervention (PCI) or coronary bypass graft surgery (CABG) over medical therapy in patients with stable moderate to severe ischemic heart disease." But "Cardiac surgeons Joseph Sabik III, MD, and Faisal Bakaeen, MD, however, spotted that only 40 patients are in the Duke category 6 group (three-vessel severe stenosis of at least 70% or two-vessel severe stenosis with a proximal left anterior descending lesion) in Supplemental tables 1 and 2, whereas 659 are in the main paper."
The import: "The accuracy of the data has important implications because the recent AHA/ACC/SCAI coronary revascularization guidelines used the ISCHEMIA data to downgrade the CABG recommendation for complex multivessel disease . . . Several surgical societies have contested the guidelines, questioning whether the ISCHEMIA patients are truly reflective of those seen in clinical practice and questioning the decision to treat PCI and surgery as equivalent strategies to decrease ischemic events."
Cardiac Testing Recovers From the Pandemic Unevenly
A report in the Journal of the American College of Cardiology (here) and a summary in Medscape (here) found that "Cardiovascular diagnostic testing has yet to return to prepandemic levels in some regions of the world, and that excess pandemic-related stress among physicians and testing staff may be slowing that recovery . . . cardiac diagnostic procedure volumes took a direct hit in the early days of the COVID-19 pandemic, falling 64% globally."
"Procedure volumes continued to decrease and recovery lagged, however, in Latin America (17% decrease from 2019; 79% recovery rate), Middle East and South Asia (33% decrease; 58% recovery), and Africa (42% decrease; 45% recovery). By 2021 . . . testing in lower-middle- and low-income countries remained depressed, at levels 58% and 48% of those before COVID-19, respectively (recovery rates, 46% and 30%, respectively)."
HOSPITALS AND OTHER HEALTH CARE FACILITIES
RAND Continues Surveys of Hospital Payments as a Multiple of Medicare Payments
The fourth round of RAND hospital price surveys (here) examined levels and variations of hospital prices paid by employers and private insurers across the United States from 2018 to 2020, finding that hospitals in "Some states (Hawaii, Arkansas, and Washington) had relative prices below 175 percent of Medicare prices, while other states (Florida, West Virginia, and South Carolina) had relative prices that were at or above 310 percent of Medicare prices."
"In 2020, across all hospital inpatient and outpatient services (including both facility and related professional charges), employers and private insurers paid 224 percent of what Medicare would have paid for the same services at the same facilities."
"The 224 percent total for 2020 is a reduction from the [headline making] 247 percent figure reported for 2018 in the previous study owing to an increase in the volume of claims from states with prices below the previous mean price." Without that dilution, "2020 prices averaged 252 percent of Medicare, which is similar to the 247 percent relative price reported in the previous round for 2018."
According to the researchers, "Very little variation in prices is explained by each hospital's share of patients covered by Medicare or Medicaid; a larger portion of price variation is explained by hospital market power."
"Prices for COVID-19 hospitalization were similar to prices for overall inpatient admissions and averaged 241 percent of Medicare."
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Proposed IPPS Rule for FY 2023 Published in Federal Register, Clock Begins
(Fourth of a continuing series)
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 the May 10 Federal Register, here. Comments are due by June 17. The final rule, published usually in late summer, would be effective October 1, 2022.
Among its many provisions, the proposed rule includes requests for information on these topics: "The impact of climate change on outcomes, care, and health equity; Measuring healthcare quality disparities across CMS quality programs; The use of fast healthcare interoperability resources (FHIR) in CMS quality programs; and Payment adjustments under the IPPS and outpatient prospective payment system for domestically manufactured N95 respirator masks."
Standardized average payment amount increases of 1.4% are subject to numerous adjustments, mostly downward, as explained by the Healthcare Financial Management Association in its 198 page summary (here) of the proposed rule. For example, "The HRRP [hospital readmission reduction program] program is estimated to reduce FY 2023 payments to an estimated 2,364 hospitals or 81.6 percent of all hospitals eligible to receive a readmissions penalty. The proposed readmissions penalty is estimated to affect 0.50 percent of payments to the hospitals that are being penalized for excess readmissions." For another example, "The standardized amounts do not include the 2 percent Medicare sequester reduction that began in 2013 and will continue until at least 2030 under current law. The sequester reduction is applied as the last step in determining the payment amount for submitted claims and does not affect the underlying methodology used to calculate MS-DRG weights or standardized amounts. (The sequester reduction was suspended during the pandemic beginning May 1, 2020, through March 31, 2022, and is 1 percent from April 1, 2022, through June 30, 2022)."
The widely publicized 3.2% increase in payment per service, therefore, will be much less for most hospitals, and, on average, there will be a reduction of Medicare payments to hospitals in FY 2023. "CMS estimates that the proposed rule will decrease FY 2023 combined operating and capital payments to approximately 3,141 acute care hospitals paid under the IPPS by an estimated $0.4 billion."
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 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