DCMedical News: Thursday, June 16, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Thursday, June 16, 2022
MedPAC, MACPAC, Report to Congress
The Congressionally chartered advisory bodies on Medicare and Medicaid made their June reports to Congress, here and here.
MedPAC (executive summary here) emphasized six themes in its recommendations. In the first, the group made recommendations to “operationalize our June 2021 recommendation that CMS reduce the number of Medicare alternative payment models (APMs) and design models to work better together.” The “models” famously conflict, produce excessive and burdensome paperwork for physicians and, in the end, have failed to save money for Medicare.
MedPAC also attends to the needs of beneficiaries who reside in a medically underserved area (MUA), are dually eligible for Medicare and Medicaid, or have multiple chronic conditions, and examines whether new Medicare safety-net funding might be warranted in a health care [provider] sector. “We apply our framework to identify safety-net hospitals, evaluate the financial performance of safety-net hospitals, and model the redistribution of current disproportionate share hospital (DSH) and uncompensated care payments using our safety-net hospital metric.”
The price of drugs does not escape MedPAC attention, including (for Part B) “high launch prices for new ‘first-in-class’ drugs with limited clinical evidence, high and growing prices among products with therapeutic alternatives, and financial incentives associated with the percentage add-on to Medicare Part B’s payment rate.”
Gaming of reimbursement by Medicare Advantage plans is also a priority. As the Commission puts it: “the influence of outliers in the CMS hierarchical condition category (HCC) risk-adjustment model used to adjust payments to Medicare Advantage (MA) plans.”
The continuing quest for “site of service” equality—lowering hospital outpatient clinic and “provider-based” physician office fees to the level of independent physician practices—not “adjusting” in the other direction—is the last of the major MedPAC priorities.
MACPAC, the Medicaid and CHIP Payment and Access Commission, put its emphasis (news release here) on “a better system for monitoring access to care for Medicaid beneficiaries, improve the oversight and transparency of managed care directed payments, increase access to vaccines for adults enrolled in Medicaid, encourage the uptake of health information technology (IT) in behavioral health, and better integrate care for people who are eligible for both the Medicaid and Medicare programs.”
A theme in common in the two reports—“managed” Medicare and “managed” Medicaid—how to ensure that the privatized programs serve the intended beneficiaries, and not only their shareholders.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Indirect (“Incident to”) Billing by NPs and PAs Under Scrutiny
A study in Health Affairs (here) puts the spotlight on “indirect billing” by nurse practitioners and physician assistants. “Nurse practitioners (NPs) and physician assistants (PAs) represent a growing share of the health care workforce, but much of the care they provide cannot be observed in claims data because of indirect (or ‘incident to’) billing, a practice in which visits provided by an NP or PA are billed by a supervising physician.”
“If NPs and PAs bill directly for a visit, Medicare and many private payers pay 85 percent of what is paid to a physician for the same service . . . we estimated that the number of all NP or PA visits in fee-for-service Medicare data billed indirectly was 10.9 million in 2010 and 30.6 million in 2018. Indirect billing was more common in states with laws restricting NPs’ scope of practice.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Hospital Utilization for COVID-19 Patients Varied Widely in Europe
A study (here) in Health Policy found that “Hospital and ICU capacity varied widely across countries . . . utilisation of acute care bed capacity by patients with COVID-19 did not exceed 38.3% in any studied country . . . the Netherlands, Sweden, and Lombardy would not have been able to treat all patients with COVID- 19 requiring intensive care during the first wave without an ICU surge capacity. Indicators of hospital utilisation were not consistently related to the number of SARS-CoV-2 infections . . the mean number of hospital days associated with one case ranged from 1.3 (Norway) to 11.8 (France).”
Which Countries Followed This Course With COVID-19?
A second study from Health Policy (here) described four countries which “implemented harsh transmission prevention measures at the beginning of the pandemic and managed to effectively avoid the first wave of infections during spring . . . all four relaxed most of these measures during the summer and experienced uncontrolled growth of cases.”
“Along the way, there has been an erosion of public support for the government measures. This was mainly due to economic considerations taking precedent but also likely due to diminished trust in the government. All four countries have been overly reliant on their relatively high bed capacity, which they managed to further increase at the cost of elective treatments, but this could not always be supported with sufficient health workforce capacity. Finally, none of the four countries developed effective find, test, trace, isolate and support systems over the summer despite having relaxed most of the transmission protection measures since late spring. This left the countries ill-prepared for the rise in the number of COVID-19 infections they have been experiencing since autumn 2020.”
The answer? The “Visegrad Group (V4) was formed in 1991 by the heads of the Czechoslovak Republic, now Czechia and Slovakia, Hungary and Poland.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Prior Authorization Backlash: Spanner in the Works, or a Blank Check?
Bloomberg Health & Law reports (here) that the continued march of Medicare Advantage (MA) plans to profitability may be undone by their use of “prior authorization.” The report notes that “Medicare’s steady transition from its founding fee-for-service care model has hit a serious snag with the growing flap over coverage denials by the program’s private managed care plans.”
“In recent weeks, however, lawmakers, providers, patient advocates, and a government watchdog agency report have raised concerns that MA plans are using prior authorization to improperly deny medical care that fee-for-service Medicare typically covers. . . The growing backlash has renewed calls for the Centers for Medicare & Medicaid Services to require greater transparency and oversight of MA plans, which were paid $350 billion in 2021 and could become the dominant coverage option for Medicare’s 64 million-plus beneficiaries in 2023.”
For America’s Health Insurance Plans (AHIP), the CEO countered that “certain provider organizations would prefer that all clinicians be given a blank check to order any test or procedure at any time, regardless of the expected value or expense to the patient. But giving clinicians carte blanche is no way to improve health care affordability and access for every American.” Using results of studies from the Kaiser Family Foundation, the Bloomberg report (see graph) notes that 87% of opioid treatment, 90% of diabetic supplies and 98% of Part B (outpatient) drugs require prior authorization.
READINGS & REFERENCES
Select Coronavirus Public Health Resources and References may be found here.
Monkeypox resources, CDC (here), JAMA Patient Page (here).
2022 CQ Congressional Calendar here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
June 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