DCMedical News: Wednesday, December 7, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, December 7, 2022
How Many People Will Be Newly Uninsured When the Public Health Emergency Ends?
The Urban Institute (report here, Becker’s coverage here) says 3.8 million people are likely to become uninsured once Medicaid redeterminations restart, including about 1.5 million who are eligible for, but don’t enroll, in Affordable Care Act coverage. However, even that significant number assumes that the great majority of the 18 million or so Americans expected to lose Medicaid coverage will transition to employer-sponsored coverage, the Children’s Health Insurance Program or a market plan under PPACA.
CQ noted that, in the run-up to legislation prior to December 16, when government funding would expire, “There is also a sense of urgency because of the looming expiration of the public health emergency. During the COVID-19 public health emergency, states are barred from removing people from the Medicaid rolls, even if they might no longer quality for coverage.”
InsideHealthPolicy (here) noted “The unwinding will have a varying impact on states’ uninsurance rates, with 19 states expected to see a spike of more than 20%, and policy decisions made during the transition will have a critical effect on how many residents lose Medicaid, how quickly they lose coverage, and whether they transition to other insurance, the study finds.”
“We anticipate that the end of the PHE will cause the biggest changes in coverage since the implementation of the Affordable Care Act more than a decade ago,” said Katherine Hempstead, senior policy advisor at the Robert Wood Johnson Foundation (RWJF), which funded the analysis. “There is a big range in potential outcomes, and a lot depends on what states do to try to keep people connected to coverage.” The Urban Institute study assumed “The largest share of people losing Medicaid - or about 9.5 million Americans - will end up with employer-sponsored coverage.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
MIPS: A Value-Based Slogan
A study in this week’s JAMA (here) notes that “The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide.” Now a little more is known, and essentially confirms that the MIPS program is a slogan with only tenuous connection to merit.
The study is a “cross-sectional observational study of 80,246 primary care physicians.” The results showed that “MIPS scores were inconsistently related to performance on process and outcome measures, and physicians caring for more medically complex and socially vulnerable patients were more likely to receive low MIPS scores, even when they delivered relatively high-quality care.”
An editorial in the same edition (“Pay for Performance: When Slogans Overtake Science in Health Policy,” here) notes that “From the outset, the pay-for-performance movement has been propelled by calls to pay for ‘quality instead of quantity,’ ‘value instead of volume,’ or ‘health instead of health care.’ The logic of these slogans seems unassailable —who would not want to get more for their money by spending it on something better? Yet an accumulated body of theory and evidence questions whether pay for performance is sound policy.”
“A core challenge is that health care quality is complex—a slippery, multidimensional construct that has evaded attempts to capture it accurately and comprehensively with a tractable measure set. In this issue of JAMA, the study by Bond et al of the Merit-based Incentive Payment System (MIPS) is a reminder that redistributions resulting from pay for performance are sensitive to measure selection . . . suggesting that the MIPS program does not reward the care society wants . . . Moreover, extrinsic financial incentives applied to measured aspects of quality can detract attention and resources from harder-to-measure but important aspects and undermine the intrinsic motivation of clinicians to do what they think is best for patients. Consequently, overall quality may not progress and could even suffer.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Treat and Release: Is the Increase in High Intensity Billing Due to Changes in Patients, Coding or Fraud?
In Health Affairs (here), a study of emergency department visits found that “In 2006, 4.8 percent of treat-and-release ED visits exhibited high-intensity billing, and this figure rose to 19.2 percent by 2019.” “High-intensity billing, with larger reimbursements, may reflect upcoding, may be a correction for historical down coding . . . and may also be a consequence of broader changes in the complexity of patient presentations and expectations . . . In contrast to two decades ago, patients seeking emergency care are older, have a greater number of preexisting comorbidities, and require more intense diagnostic evaluation and treatment during an ED visit.”
“This growth in high-intensity billing has attracted scrutiny from payers. In 2012 the Department of Health and Human Services Office of Inspector General released a report finding that 21 percent of Medicare claims for emergency care services across multiple types of providers did not have adequate documentation to support the level billed, and concerns for fraudulent upcoding remain pervasive across the health care system.”
No Money in Children
Or at least less money for children’s hospital care. That is the conclusion of a Lown Institute summary (here) of why pediatric hospital beds are disappearing nationwide. “Why is pediatrics a drain on hospital finances? One reason is reimbursement. Medicaid, the state-run health insurance program for low-income patients, covers more than ⅓ of children in the US, and Medicaid reimbursement rates are typically lower than those from other insurers. But even kids covered under commercial insurance are often less profitable than adults because they have little need for elective surgeries. Elective procedures like joint replacements or heart surgeries, which are profitable for hospitals, are much more common among older adults. Low-value imaging tests are also less common for kids because pediatricians often try to avoid unnecessary radiation — that’s less money for the hospital too.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Where Does the Medicaid DSH Money Go?
A study in Health Affairs (here) addresses that question. “Medicaid disproportionate share hospital payments . . . are intended to support hospitals that serve low-income patients.” This study “employed alternative definitions of targeting, or the degree to which allocations were made in a manner consistent with the statutory goals and intent of the program, to examine disproportionate share hospital payment allocations in forty-nine participating states.”
Results: “The most recent data indicate that 57.2 percent of acute care hospitals received disproportionate share hospital payments, totaling more than $14.5 billion, in 2015.” “However, among all hospitals receiving these payments, up to 31.6 percent of payments were allocated to hospitals that did not meet a given definition, and 3.2 percent went to hospitals that met none of them.”
MACPAC in Town
The Medicaid and CHIP Payment and Access Commission will meet virtually this Thursday and Friday (notice here). Among the topics for the group, “Potential recommendations for Medicaid coverage based on a Medicare national coverage determination; a panel discussion on the role of Medicaid in improving outcomes for adults leaving incarceration; MACPAC’s required annual analysis of Disproportionate Share Hospital allotments.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
December 8, 12, 13, 14, 15
January 3, 4, 5, 9, 10, 11, 12, 24, 25, 26, 27, 30, 31
February 1, 2, 6, 7, 8, 9, 27, 28
March 1, 7, 8, 9, 10, 22, 23, 24, 27, 28, 29, 30
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org