DCMedical News: Monday, November 14, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Monday, November 14, 2022
Congress Returns for Post-Election Session. Physician Fees, Hospital Reimbursement, PHE Measures
Congress is back in session (both the Senate and the House) for at least seven days in November and ten days in December, ending December 15. On the docket:
Hospital payments under the Medicare program for 2023.
The Medicare “sequester” of 4% will be imposed January 1, short of Congressional action. The Federation of American Hospitals outlines the issues and the rationale for reversing the sequester (here). The Federation also spoke up on behalf of Medicare pay bumps for rural hospitals, repair for Medicare physician fees in 2023, application of brakes on the accelerating Medicare Advantage abuse of prior authorization, and extension of PHE innovations (all below).
PHE (Public Health Emergency) measures.
Expedited Medicaid qualification, telehealth and the hospital without walls, all pandemic changes rapidly implemented, but scheduled to expire.
Medicare Advantage Reform.
Congressional action to rein in overcoding among the popular Medicare Advantage programs is unlikely, especially since CMS struggles to use current authority, even in the face of documented abuse.
InsideHealthPolicy reports (here) “[The] administration announced on Friday (Oct. 28) it is punting finalizing a rule on MA risk adjustment to 2023 while it sorts out how to handle overpayments . . . CMS announced an additional three-month extension of the timeline for publication of a final rule – which it initially proposed in 2018 – until Feb. 1, 2023.”
“Several reports from the HHS Office of Inspector General and the Government Accountability Office have alleged risk-adjustment payment opportunities incentivized plans to make beneficiaries look as sick as possible in their documentation, leading to billions in overpayments.”
“A Sept. 29 report from the Office of Inspector General found that, for 160 of the 226 sampled enrollee-years in an audit of MA insurer Highmark, the diagnosis codes were not supported in the medical records, resulting in an estimated $6.2 million of net overpayments in 2015 and 2016. . . . increases in coding intensity could raise Medicare expenditures by $200 billion over a decade.”
Also unlikely: a remedy for misleading MA advertising (here), especially important given the turnover of MA plan enrollees, as reported (here) in The American Journal of Managed Care. “New MA enrollees change insurers at a substantial rate when followed across multiple years. These changes may disincentivize insurers from investing in preventive care and chronic disease management and as shown in several non-MA populations, may lead to discontinuities in care, increased expenditures, and inferior health outcomes.”
Letters to The New York Times in response to reporting on MA abuses (here) include this from Center for Medicare Advocacy’s Judith Stein: “It’s beyond comprehension that the subject of this article is not a major scandal. Not only are wasteful payments to private Medicare Advantage plans straining Medicare’s finances, but they are also crowding out expansion of benefits for the half of Medicare beneficiaries who choose to remain in traditional Medicare. For example, even using the article’s conservative overpayment estimates ($12 billion in 2020), the overpayments are “enough to cover hearing and vision care for every American over 65.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
The Leading Cause of Death Associated With Childbirth in the U.S. is Homicide
A note in BMJ (here) reports that “Women in the US are more likely to be murdered during pregnancy or soon after childbirth than to die from the three leading obstetric causes of maternal mortality (hypertensive disorders, haemorrhage, or sepsis).”
The note contends that “These pregnancy associated homicides are preventable, and most are linked to the lethal combination of intimate partner violence and firearms. Preventing men’s violence towards women, including gun violence, could save the lives of hundreds of women and their unborn children in the US every year.”
CDC has a new study on the preventability of pregnancy-related deaths (here), concluding that “Among the 1,018 pregnancy-related deaths, a preventability determination was made for 996 deaths. Among these, 839 (84%) were determined to be preventable.” A comment on the CDC report (here) in JAMA notes “More than half of the deaths in the study occurred after the first week through 1 year after delivery . . . [an author] said he hopes the report raises clinician awareness about the risks that extend through a year after delivery.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Administrators and Physicians
AthenaHealth reports (here) that “While the number of practicing physicians in the U.S. grew 150 percent between 1975 and 2010, the number of health care administrators increased 3,200 percent during the same period.”
Hospital Naming, “Redefinitions”
CMS earlier this year proposed “Rural Emergency Hospital” designation for health facilities which would not be hospitals, that is, which would have no inpatient beds or services. Now the AHA is proposing a new designation for inner city safety net hospitals, the “Metropolitan Anchor Hospital,” (here) which would apply to one of eight urban hospitals. Since 1992, with the beginning of the 340B pharma discount/hospital pay program, the definition of a “safety net” hospital has been altered by, among other factors, the success (for hospitals) of that program, now with more than 2,500 participating facilities. AHA “fact sheet” here.
DRUGS & DEVICES
Step Therapy and A-Fib
A study in The American Journal of Managed Care (here) shows that “Limiting access to non–vitamin K antagonist oral anticoagulants [NOACs] through step therapy and prior authorization may exacerbate current underuse of anticoagulants and increase the risk of stroke in patients with newly diagnosed atrial fibrillation.”
Background: “NOACs are considerably more expensive [than warfarin] and, until recently, lacked a reversal agent to mitigate the risk of life-threatening bleeding. Some health plans initially excluded NOACs from coverage or chose to restrict access to them through the use of prior authorization (PA) and step therapy (ST) requirements. Under PA, the health plan or pharmacy benefit manager must authorize a particular prescription before it can be covered. Under ST, also called “fail first,” patients must try and fail to reach therapeutic target on a lower-cost alternative, in this case warfarin, before receiving authorization for the originally requested medication . . . if not used judiciously, they can induce patients to delay treatment, switch to less effective medications, or become nonadherent and, as a result, experience adverse health effects.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
November 15, 16, 17, 18, 29, 30
December 1, 2, 5, 6, 7, 8, 12, 13, 14, 15
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org