DCMedical News: Monday, July 18, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Monday, July 18, 2022
United Solves Insulin Cost Problem, Announces $5 Billion Quarterly Profit on $80 Billion Revenue (Up 13%)
Seeking Alpha reports that “UnitedHealthcare (NYSE:UNH) will offer certain preferred prescription medicines, including insulin and other emergency use drugs, for $0 cost share to its standard insured group plans. UNH said out-of-pocket costs will be eliminated for eligible members for insulin and other drugs to treat emergencies such as allergic reactions, low blood sugar, opioid overdose and asthma attacks.”
The zero co-pay will be offered to fully underwritten group plans as early as January 1, 2023. The other four preferred medicines to be included in the new offering will be epinephrine for allergic reactions, glucagon for low blood sugar, naloxone for opioid overdoses, and albuterol for asthma attacks. The transcript of United’s quarterly earnings report is here.
Is food next? From the transcript: “The simplicity of combining all benefits, even healthy food purchases onto a single widely-accepted card has been a differentiator with consumers. Based on this initial work, we intend to introduce the card to all our individual Medicare Advantage members in 2023.”
Senate Settles On “Health” Bill, Not Including Climate Measures
CQ reports (here) that “President Joe Biden on Friday endorsed a plan hatched by two key Senate Democrats to pass a budget reconciliation package that would help lower the cost of prescription drugs and protect millions of households from health insurance premium spikes, even if it leaves out important clean energy priorities.”
“[Senator] Manchin said he told [Senate Majority Leader] Schumer, D-N.Y., that if legislation must move before the August recess, he could only support parts of the budget reconciliation package that would allow Medicare to negotiate prices with pharmaceutical companies and extend expanded health care premium subsidies for two years.”
CQ noted that the “problem for top Democrats is that by mid-August, many states will announce premiums for health insurance purchased on the exchanges set up by the 2010 health care law (PL 111-148, PL 111-152). Notices will go out in October — well in advance of the midterm elections — and if the subsidies aren’t extended by then, consumers will see their premiums will increase significantly. So the urgency of extending those larger exchange subsidies combined with passing prescription drug pricing legislation, which many Democrats view as delivering on a prime campaign promise, may be enough to get a health care-only budget package over the finish line for starters.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Two Problems Collide, With No Obvious Solutions
The New York Times reports (here) that “American hospitals are once again filling up with coronavirus patients — but not with nurses to care for them. The nation’s chronic shortage of registered nurses is as bad in some parts of the country as it has ever been, experts say, and it is showing signs of getting worse.”
“Hospitalizations have risen steadily in recent weeks, and the daily average number of people in hospitals who are infected with the coronavirus now exceeds 39,000, the highest it has been since the waning days of the first Omicron surge in early March. The rise is being driven largely by BA.5, a rapidly spreading Omicron subvariant that is the best yet at evading some antibodies from previous infections or vaccines.”
The report continues, “But in the face of the growing need, hospitals across the country say they still cannot find enough nurses. In New York State, the shortage is at an ‘all-time high,’ said Matthew Allen, a registered nurse at Mount Sinai Hospital in New York City and a board member of the New York State Nurses Association. ‘It’s just historic, more than it’s ever been before,’ Mr. Allen said, noting that as of last week, Mount Sinai’s hospital network alone had 771 unfilled registered nurse and nurse practitioner positions.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Hospital OPPS Proposed Rule for FY 2023 Published: 2.7% Increase; 5% Bump and Additional Payments for REHs
The proposed rule for outpatient hospital, ASC and other payments through the Medicare program for fiscal year 2023 (October 1, 2022ff) was published in preliminary form (here, 886 pages) July 15 in the Federal Register, with publication of the final proposed rule scheduled for July 26, followed by a comment period.
The formal title of the proposed rule, “Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Organ Acquisition; Rural Emergency Hospitals: Payment Policies, Conditions of Participation, Provider Enrollment, Physician Self-Referral; New Service Category for Hospital Outpatient Department Prior Authorization Process; Overall Hospital Quality Star Rating,” indicates the scope of the proposals, summarized in a “fact sheet” (here, 16 pages).
The proposed policies will affect 3,411 hospitals and approximately 5,500 ASCs.
“In accordance with Medicare law, CMS is proposing to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.7%. This update is based on the projected hospital market basket percentage increase of 3.1%, reduced by 0.4 percentage point for the productivity adjustment. In the CY 2019 OPPS/ASC final rule with comment period, CMS finalized the proposal to apply the productivity-adjusted hospital market basket update to ASC payment system for an interim period of 5 years (CY 2019 through CY 2023). Using the proposed hospital market basket update, CMS is proposing to update the ASC rates for CY 2023 by 2.7%. The proposed update applies to ASCs meeting relevant quality reporting requirements. This update is based on the projected hospital market basket percentage increase of 3.1%, reduced by 0.4 percentage point for the productivity adjustment.”
More information is providing on the new category (see DCMN of 7-15-2022) of Rural Emergency “Hospitals,” as follows. “REH services include emergency department services, observation care, and may include other outpatient medical and health services as specified by the Secretary. Covered outpatient department services provided by REHs will receive an additional 5% payment for each service . . . REHs will also receive a monthly facility payment. After the initial payment is established in CY 2023, the payment amount will increase in subsequent years by the hospital market basket percentage increase.”
“To improve access to all types of care in rural settings, CMS is proposing to consider all covered outpatient department services (that is, services that would otherwise be paid under the OPPS) as REH services. REHs would be paid for furnishing REH services at a rate that is equal to the OPPS payment rate for the equivalent covered outpatient department service increased by 5%. CMS is also proposing that REHs may provide outpatient services that are not otherwise paid under the OPPS (such as services paid under the Clinical Lab Fee Schedule).”
Also included in the proposed rule is a loosening of Stark law restrictions for the REHs, as well as payment for outpatient services in off-campus provider sites for Rural Sole Community Provider hospitals at the OPPS rate, not the PFS (physician fee schedule, 40% lower) rate.
Prior authorization creep in the proposed rule: “CMS continues to prioritize reducing unnecessary increases in the volume of certain covered outpatient department (OPD) services through the use of a prior authorization process. In the CY 2023 OPPS/ASC proposed rule, CMS is proposing to require prior authorization for an additional service category: Facet Joint Injections and Nerve Destruction. This proposal would ensure Medicare beneficiaries receive medically necessary care while protecting the Medicare Trust Funds from unnecessary increases in volume by virtue of improper payments without adding new documentation requirements for providers.”
READING & 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
July 19, 20, 21, 26, 27, 28, 29
August, Congress adjourned, no editions of DCMN
September 13, 14, 15, 16, 19, 20, 21, 22, 28, 29, 30
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org