DCMedical News: Tuesday, December 13, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Tuesday, December 13, 2022
Congress Winds Up, and Down: Can Physician Fee Cuts Be Avoided? How About Amputations?
CQ reports (here) that “Lawmakers said to be on verge of a bipartisan omnibus agreement” and that “House and Senate negotiators appear to be close to reaching agreement on a bipartisan omnibus spending deal that could be announced as early as Tuesday [today].”
“The deal, if it comes, would pave the way for final fiscal 2023 appropriations that congressional leaders hope to pass by next week. However, the details of that potential agreement, including how — and if — it would bridge the parties’ multibillion-dollar gap on nondefense funding, remain under wraps.”
InsideHealthPolicy (here) reports that “Almost half the Senate and more than 130 House members have publicly called to avert upcoming 2023 pay cuts to doctors, according to the Surgical Care Coalition -- but while most expect a fix will move forward if there is a vehicle to attach it to, some lobbyists are becoming less optimistic an omnibus deal will be reached this year despite reported progress over the weekend and Senate Majority Leader Chuck Schumer (D-NY) teeing up a one-week continuing resolution on Dec. 16 to give lawmakers an extra week to negotiate.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
InsideHealthPolicy (here) also reports on one of the less attractive phenomena associated with physician lobbying for Medicare fees, namely threats to curtail services. In this case, the cuts are literal, with one group predicting more amputations if fees for revascularization are not “fixed.”
Says IHP, “[T]he CardioVascular Coalition is calling on Congress to stop payment cuts to revascularization services provided under the physician fee schedule, as the group says the cuts could exacerbate an epidemic of amputations.”
On the website of CardioVascular Coalition (here), Dr. Paul Gagne explains the group’s position: “Unless Congress Acts, Ongoing Clinical Labor Cuts Will Worsen Amputation Epidemic. There is a little-known epidemic occurring in the medical world that will be made worse if Congress does not act to stop the ongoing clinical labor cuts outlined in the 2023 Medicare Physician Fee Schedule finalized rule.”
“The amputation epidemic is a troubling trend of preventable leg amputations being performed on patients, particularly people of color. Surgeons perform about 200,000 non-traumatic amputations annually, most of them due to peripheral artery disease (PAD), a common complication of diabetes, kidney disease and chronic hypertension . . . As many as 85% of those amputations could be prevented with early diagnostics and treatment.”
“The final rule for 2023 Medicare Physician Fee Schedule, released by the Centers for Medicare & Medicaid Services (CMS), would impose cuts of up to 9% on doctors in outpatient facilities who provide revascularization services, which are necessary to prevent leg amputation of patients with PAD.”
“We spend many millions of dollars treating patients who have had amputations addressing their disability, artificial leg needs, progression of other diseases associated with the inability to walk, depression due to loss of independence and the nursing home care necessary when patients lose the ability to care for themselves with loss of ambulation.”
“Much of this could be avoided with patients having a better quality of life if we prevented the amputations. The fee schedule rule would adversely affect important sites of care, namely OBLs, or office based labs, where preventing amputations is our main focus. This is not a task that our post pandemic stretched hospitals can assume. This requires increased access for our most vulnerable patients that is filled by OBLs. If the cuts are implemented, they will disrupt patients’ access to treatment, lead to higher amputation rates and worsen racial inequities.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Medicare in 2023
MedPAC gave a preview of its recommendations for 2023 during its December 8-9 meeting. The advisory group to Congress considered the adequacy of payment to various Medicare providers.
For hospitals (presentation by staff to MedPAC members here), it appears that MedPAC is pursuing its course of a separate and complementary set of recommendations to Congress on “Supporting Medicare safety-net hospitals,” a new appellation and focus this year.
In background information, the financial health of hospitals is assessed. The general question presented each year is, “Are Medicare beneficiaries able to find acute general hospital services in sufficient quantity and at acceptable quality?”
For example, it is noted that the number of general acute care hospital closings and openings were equal in fiscal years 2021 and 2022 (11 and 16, respectively), compared to 2019, which had 46 closures and 12 openings. Hospital occupancy varied widely with time and geography: in aggregate, 65% of inpatient bed days were occupied in 2021, but some hospitals neared capacity at times. The percent of hospitals reporting critical staff shortages peaked at 20% in December of 2020, remained around 15% or so in 2021, but declined to 5% in 2022.
CMS continues to claim that hospitals enjoy an 8% profit margin in serving Medicare patients. However, CMS (and MedPAC) only measure marginal cost in calculating profit, that is, assuming that Medicare has no responsibility for fixed building and capital costs. Remarkably, the staff presentation reports that “The rapid response to the coronavirus epidemic has demonstrated that many hospitals can substantially lower their costs in response to declining volume over a matter of months.”
Inpatient stays by Medicare beneficiaries have declined significantly from 2017 (252 per 1,000 Medicare beneficiaries) to 2021 (208).
As a result of its interpretation of hospital costs for which Medicare is responsible, and also counting Provider Relief Funds and foregone Paycheck Protection Program forgiveness as part of a hospital’s profit margin, the staff concludes that “Hospitals’ payment adequacy indicators remained generally positive in 2021.”
The presentation explores the plight of safety net hospitals and their Medicare patients, proposing a new “Safety net Index,” add-on payments which would be required of both the fee-for-service (traditional) Medicare program, and of Medicare Advantage plans.
Additional staff presentations reported on payment adequacy for hospice (here), outpatient dialysis (here), physicians and other Part B professionals (here), ambulatory surgery centers (here), home health care (here), inpatient rehabilitation hospitals (here), and skilled nursing facilities (here).
Tomorrow, Medicaid in 2023, the MACPAC meetings of December 8-9.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
December 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