DCMedical News: Thursday, September 15, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Thursday, September 15, 2022
Child Poverty Down
A report in The New York Times (here) says “Child poverty has fallen 59 percent since 1993, with need receding on nearly every front. Child poverty has fallen in every state, and it has fallen by about the same degree among children who are white, Black, Hispanic and Asian, living with one parent or two, and in native or immigrant households.” On the other hand, Statista reports (story here, chart here) that life expectancy in the U.S. plunged in pandemic years 2020-2021, and that “The new figure marks the lowest life expectancy estimates since 1996 and is the biggest two-year fall in nearly a century.”
Medicare Advantage Carriers Suffer Setback Over “Prior Authorization”
The House of Representatives quickly marked up and passed legislation Wednesday which will curb the profit of health insurers with Medicare Advantage (MA) plans, sharply limiting their ability to demand “prior authorization” for services which, under traditional Medicare, would be paid for.
The vote came just hours after a House subcommittee also approved by voice vote the bill (HR 3173), which aims to require Medicare Advantage plans to accept requests electronically and to provide “real-time” decisions for services that are routinely approved. Turnaround on the bill was so quick that the full House vote occurred even as the subcommittee continued its markup on other bills on its agenda.
The measure would compel Medicare Advantage insurers to use electronic prior authorization programs, annually submit lists of items and services subject to prior authorization, and adopt beneficiary protection standards. The Improving Seniors’ Timely Access to Care Act now moves the Senate, where supporters hope it will advance after the November congressional elections.
Modern Healthcare reports “Prior authorization in Medicare Advantage has come under fire this year. Approximately 13% of denied prior authorization requests during a week-long period in June 2019 met fee-for-service Medicare coverage rules, according to a Health and Human Services Department report released in April. Hospitals have called on the Justice Department to use the False Claims Act against Medicare Advantage insurers that improperly deny coverage.”
The spanner in the works: “I think we've all heard from constituents and physicians in our districts on this issue,” said Rep. Anna G. Eshoo, D-Calif., chair of the subcommittee. “Prior authorization has morphed into a costly, inefficient mechanism that requires many practices to hire extra staff and causes delays that often lead to patients abandoning treatment."
Additional cost to the Medicare program? The Congressional Budget Office found the bill would increase costs to Medicare by “billions” over 10 years, but Rep. Larry Bucshon, R-Ind., and a thoracic surgeon, noted such estimates show increased costs to Medicare only because it would stop plans that are “failing” to follow the law. “They're using prior authorization to deny payment for services that are covered by traditional Medicare,” Bucshon said. “Therefore, a score based on current law should not reflect a change in utilization if plans were following the law."
More on MA plans: a study in JAMA (here) finds that quality of the MA plans does not necessarily vary with price; one from Brookings (here) finds that MA plans owned by large, multi-faceted health insurance companies spend as much as 70% of their premium income on products and services sold by their own subsidiaries; a study from Kaiser Family Foundation (here) examines the impact on individual beneficiaries of alternative MA plans; and CMS wraps up a 30 day “Request for Information” (here) on how to improve MA plans, a Brookings-Schaeffer response here.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Fixing the Medicare Physician Fee Schedule
CQ reports that “A bipartisan pair of lawmakers have introduced legislation that would increase payments for physicians participating in Medicare by 4.42 percent in 2023. The bill (HR 8800), introduced by Reps. [Dr.] Ami Bera, D-Calif., [a general practitioner] and [Dr.] Larry Bucshon, R-Ind., [a thoracic surgeon] Tuesday would partially offset a 4.5 percent cut the Biden administration has proposed to take effect next year for providers paid through the Medicare Physician Fee Schedule. The duo have been successful in getting similar legislation added to omnibus spending laws for the past two years, but it is not yet clear how they'll do it this year or whether they'll be successful.”
CQ adds, “Without action from Congress, the Medicare conversion factor, which is used to calculate billing codes into payment rates, would see a 4.5 percent cut, amounting to about $3 billion or $4 billion less for providers paid under the Medicare Physician Fee Schedule. The cuts stem from a 2020 decision by the Centers for Medicare & Medicaid Services to increase payments for underpaid services like primary care and maternal health. To comply with budget neutrality requirements in a 2015 Medicare payments law (PL 114-10), CMS has had to make an overall negative adjustment to all physician payments. As in past years, more expensive specialties like radiology, surgery and podiatry are estimated to see the largest cuts, ranging from 4 to 7 percent. Congress stepped in to partially offset the cuts by boosting payments across the board by 3.75 percent for 2021 (PL 116-260) and 3 percent for 2022 (PL 117-71). The most recent bump expires at the end of the year.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
AHA and Rural Hospital Closures
The American Hospital Association today released a new report (here) on the causes of 136 rural hospital closures from 2010 to 2021, with 19 closures in 2020 alone. The suspects: low reimbursement, staffing shortages, low patient volume and high regulatory barriers, and the COVID-19 pandemic. “Recently, expenses for labor, drugs, supplies and equipment have also increased dramatically, ultimately causing difficulties in maintaining access to care for people in rural communities.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
September 16, 19, 20, 21, 22, 28, 29, 30
October 11, 12, 13, 14, 17, 18, 19, 20, 21
November 14, 15, 16, 17, 18, 29, 30
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org