DCMedical News: Friday, November 18, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session. Publication will resume November 29, following the Thanksgiving recess.
THE BIG STORY Friday, November 18, 2022
CMS Finalizes Calendar Year 2023 Outpatient Hospital and ASC Rates for Medicare
The Centers for Medicare & Medicaid Services (CMS) released the final calendar year 2023 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Rule (1561 pages, here) on November 1. (A press release is here, “fact sheet” here.) The final rule will be published in the Federal Register November 23. The rule includes proposals to update payment rates, policies and regulations affecting Medicare services furnished in hospital outpatient departments and in ASC settings beginning Jan. 1.
The payment rates under OPPS and the ASC payment system would go up by 3.8% for CY 2023, minus a downward adjustment of 3.09% due to increased expenses in the 340B payment program. In that program, the 340B hospital reimbursement will revert from average sales price (ASP) minus 22.5 percent to ASP plus 6 percent because of a Supreme Court decision favoring hospitals. To maintain budget neutrality, all nondrug services for CY 2023 will receive a minus 3.09 percent payment reduction.
Services subject to prior authorization will now include facet joints, beginning July 1, 2023. The rule will also eliminate 11 services from the inpatient-only list.
CMS singled out “Behavioral Health Services Furnished Remotely by Hospital Staff to Beneficiaries in Their Homes” for continued payment beyond the end of the Public Health Emergency. “CMS is finalizing its proposal to consider behavioral health services furnished remotely by clinical staff of hospital outpatient departments, including staff of critical access hospitals (CAHs), through the use of telecommunications technology to beneficiaries in their homes, covered outpatient services for which payment is made under the OPPS. Currently, this flexibility is available through the PHE-specific policy referred to as Hospitals Without Walls (HWW), but the emergency waivers that enable this flexibility will expire when the PHE for COVID-19 ends.”
However, payment “may only be made if the beneficiary receives an in-person service within 6 months prior to the first time hospital clinical staff provides the behavioral health services remotely, and . . . there must be an in-person service without the use of communications technology within 12 months of each behavioral health service furnished remotely by hospital clinical staff.” Audio only services will qualify.
CMS Finalizes Calendar Year 2023 Physician Fees for Medicare
CMS also released the final version—short of Congressional action to increase rates—of the Medicare physician fee schedule for 2023 (3304 pages, here). This rule finalized the CY 2023 Medicare conversion factor of $33.06, a decrease of $1.55 or 4.5 percent from the 2022 CF of $34.61, the result of expiration of a Congressional fix to previous shortfalls, and budget neutrality to accommodate E/M code changes.
An analysis of the rule by the AMA (here) notes that “CMS finalized its proposal to extend telehealth coverage for an additional five months beyond the end of the PHE for the codes that were only going to be on the telehealth list through the end of the PHE. CMS agreed to maintain the same payment rates for office visits provided in-person or via telehealth through the end of 2023 instead of reducing payments for telehealth visits to the facility rates.”
Significant changes take place in Evaluation and Management (E/M) Visits. “CMS adopted the revised CPT guidelines and codes and the AMA/Specialty Society RVS Update Committee (RUC) recommended relative values for additional E/M visit code families, including hospital visits, emergency department visits, home visits and nursing facility visits. These changes allow time or medical decision-making to be used to select the E/M visit level.” (Emphasis added.)
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Mischief in Patient Satisfaction Measures, A Lighter for Burnout
An opinion piece in JAMA (here) discusses the use of “patient satisfaction” surveys and measures, contending that “Public and private payers should seriously reconsider relying on these surveys to influence quality assessment and payments. At a minimum, the Medicare Payment Advisory Commission should annually evaluate the performance of quality measures such as CG-CAHPS [Clinician and Group Consumer Assessment of Healthcare Provider and Systems] to ensure that they remain fit for purpose. Without reform, current survey practices might continue inflicting burnout on physicians and bad medical care on patients.”
The author quotes Deming’s observation that “Merit rating nourishes short-term performance, annihilates long-term planning, builds fear, demolishes teamwork, [and] nourishes rivalry and politics. It leaves people bitter, crushed, bruised, battered, desolate, despondent, dejected, feeling inferior, some even depressed, unfit for work for weeks after receipt of rating, unable to comprehend why they are inferior. It is unfair, as it ascribes to the people in a group differences that may be caused totally by the system that they work in.”
MedPAC Considers Increasing Payment to Primary Care Physicians
The Medicare Payment Advisory Commission began consideration of new policy options to increase payment to primary care physicians. At its November 3-4 meeting, the group received a staff presentation (here) which began with a report on the growing number of other specialists (increasing from 446,000 to 471,000 from 2016 to 2021) and the declining number of primary care physicians (family medicine, internal medicine, pediatrics, geriatrics, dropping from 142,000 in 2016 to 135,000 in 2021). Median pay for primary care physicians was reported as $264,000, for surgeons $441,000, for radiologist $482,000.
The presentation noted that gravity does not work on evaluation and management codes (E/M), which are supposed to rise over time (due to budget neutrality), as new and therefore high Relative Value Unit (RVU) codes decline with increasingly adept use. The higher RVU codes, however, do not decline, and therefore payment for the E&M codes does not increase, passive devaluation. “Budget neutrality” also governs the political equation: all of the staff options suggested for increasing primary care pay would require reductions in specialist pay.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
More on MedPAC
Other subjects MedPAC discussed November 3-4 include development of a prospective payment system for post-acute care (here); quality measurement standards in different Medicare populations (here); and standardizing Medicare Advantage benefits (here). The complete meeting transcript is here.
Medical Debt: Two Predictions
The Urban Institute (here) publishes a study on which county characteristics predict medical debt. The answer: “Counties in Georgia, North Carolina, and Texas have the largest shares of adults unable to pay their medical bills on time. In fact, among the 100 US counties with the highest levels of medical debt in collections, 34 are in Texas, 20 are in Georgia, and 12 are in North Carolina. These three states are among the 12 that have not adopted the Medicaid expansion under the Affordable Care Act (ACA). In fact, 79 of the 100 counties with the highest levels of medical debt were in states that have not expanded Medicaid under the ACA.”
Who benefits when patients are in medical debt?
Kaiser Health Network (here) reports that “Banks and Private Equity Cash In When Patients Can’t Pay Their Medical Bills,” and that some of the banks and some of the private equity funds are affiliated with hospitals and health systems.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
November 29, 30
December 1, 2, 5, 6, 7, 8, 12, 13, 14, 15
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org