DCMedical News: Wednesday, June 8, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
Wednesday, June 8, 2022
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Workers Settle with Los Angeles’ Cedars-Sinai for 17.5% Increase Over Three Years
Fierce Healthcare reports (here) that “Cedars-Sinai Health System reached a deal for a three-year contract with more than a thousand healthcare workers who went on a five-day strike over low wages. The system and Service Employees International Union-United Healthcare Workers West announced the deal Monday that includes an average raise of 17.46% at the end of three years and improved safety measures including access to proper personal protective equipment.”
“The agreement applies to staff in maintenance, service and clinical support areas. The union initiated the strike over what it called inadequate staffing practices, worker safety concerns and low wages. A release from the union said on the strike vote that it included several job classes ranging from certified nursing assistants to transporters as well as surgical and food service technicians . . . The union said Monday that ‘nobody will make less than $21/hour by the end of the contract.’”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
AHA Publishes “Schedule H” Analysis
The American Hospital Association has published (introduction here) Schedule H tax year 2019 benchmark reports. “Each year, the AHA, assisted by Ernst & Young LLP, collects Schedule H tax filings to assist in advocacy efforts and demonstrate the benefit provided by tax-exempt hospitals and health systems to their communities.” For every tax year since 2008, hospitals which are exempt from taxation under §501(c)(3) and file returns on form 990 have been required to include Schedule H, an assessment of the “community benefits” returned by the hospital to the community in return for their tax exemption.
“This benchmark report [here] will enable a tax-exempt hospital or system to compare its community benefit reporting on Schedule H with selected benchmark groupings of other tax-exempt hospitals. It is based on data reported to the IRS by over 2,000 hospitals. Calculating community benefits based on demographic characteristics (e.g., facility type, location) requires individual hospital information specific to each characteristic. After examining the 2,372 Schedule H forms filed by tax-exempt hospitals, AHA identified 1,911 filed for a single hospital, which comprise the benchmark group for this report . . . Community benefit information has been segmented by hospital type,” in addition to bed size, and includes general medical hospitals, children’s hospitals, teaching hospitals, Critical Access Hospitals and system-affiliated hospitals.
Mathematically, most of the benefits come from what hospitals label “unreimbursed Medicaid, Unreimbursed costs from means tested government programs” and “Medicare shortfall,” that is, amounts which the hospitals calculate the expense of services to Medicaid and Medicare beneficiaries, less the reimbursement from the government programs for those services. For example, the overall mean percentage of expense devoted to community benefit by the 1911 hospitals is 13.57%. The unreimbursed Medicaid and Medicare shortfall amounts total 9.11%, or two-thirds of the total.
Detailed analysis for general medical hospitals can be found here; for Critical Access Hospitals here; for teaching hospitals here; for system hospitals here; and for children’s hospitals here.
Big Shakeup In England’s National Health Service
The Financial Times reports (here) “NHS to face biggest shake-up of leadership in decades” as the result of a report which appears aimed at management culture, incentives and opportunities. “The UK government has promised ‘the biggest shake-up in health and social care leadership in a generation’ as it published a review that criticised ‘institutional inadequacy’ in the way the NHS trained, developed and valued managers. The review by retired general Sir Gordon Messenger also found evidence of poor behaviour and attitudes among staff ‘such as discrimination, bullying and blame cultures in certain parts of the health and social care system.’”
“Matthew Taylor, Chief Executive of the NHS Confederation said the report had acknowledged that much more needed to be done to create a more diverse leadership in the NHS. ‘We can’t hide from the fact that all too often staff from ethnic minority backgrounds are still not being provided with the support they need to progress to leadership roles. We need to move beyond admiring the problem and make concrete progress in addressing it,’ he said.”
“The government came under fire this year for refusing to accept an amendment to health legislation that would have required publication every two years of an independent assessment of the NHS’ workforce needs.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
PPACA Will Send $1 Billion in Medical Loss Ratio-Related Refunds to Consumers
The Kaiser Family Foundation reports (here and here) that “Private insurance companies are expecting to pay out $1 billion in rebates to consumers this fall under an Affordable Care Act [Patient Protection and Affordable Care Act, Health Care and Education Reconciliation Act, together the ‘ACA’] provision that requires insurers to spend the bulk of customers’ premium payments on care.”
“Rebates are based on insurers’ experiences over the previous three years. This year’s total is roughly half the size of last year’s $2 billion, in part because 2021 was a less profitable year and because the 3-year window no longer includes 2018,when individual market insurers overpriced their ACA marketplace plans due to uncertainty caused by the repeal-and-replace debate and other ACA policies. This year’s rebates continue to reflect the impact of the COVID-19 pandemic, which led to a sharp reduction in health claims in 2020, when many people skipped care amid stay-at-home orders and medical offices’ closures.”
Further from KFF in background, “The Medical Loss Ratio (MLR) . . . limits the amount of premium income that insurers can keep for administration, marketing, and profits. Insurers that fail to meet the applicable MLR threshold are required to pay back excess profits or margins in the form of rebates to their enrollees. In the individual and small group markets, insurers must spend at least 80% of their premium income on health care claims and quality improvement efforts, leaving the remaining 20% for administration, marketing expenses, and profit. The MLR threshold is higher for large group insurers, which must spend at least 85% of their premium income on health care claims.”
The Washington Post Asks, “Beat cancer? Your Medicare Advantage plan might still be billing for it.”
In a report on record mining (here) the paper noted that “The aggressive billing tactics stem from incentives built into Medicare Advantage. Under the program, companies are paid a flat fee per month to provide whatever care is required for a patient based on age, gender, geography and health risk factors. To compensate plans and providers for potential costs of care for individual patients with conditions such as diabetes, heart disease or cancer, Medicare boosts the monthly payment to Medicare Advantage plans under a ‘risk adjustment’ for each additional condition . . . If companies add more risk adjustment codes to a Medicare Advantage beneficiary’s medical record to receive higher payment — but don’t spend money on the additional care — they make more money.”
“The point of larding the medical records with outdated and irrelevant diagnoses such as cancer and stroke — often without the knowledge of the patients themselves — was not providing better care . . . It was to make patients appear sicker than they were. The maneuver translated into millions of dollars in inflated bills to the federal Medicare Advantage insurance program, the government alleged in its false-claims lawsuit filed in U.S. District Court in California.”
“The case was part of a broader government crackdown on abusive billing practices in Medicare Advantage, the privatized insurance option that by next year is expected to cover more than half of all Medicare beneficiaries.”
In a sample of hundreds of cases a whistleblower audited she discovered “90 percent of diagnoses for cancer were invalid, as were 96 percent for stroke and 66 percent for fractures.”
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
June 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 editions of DCMN
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org