DCMedical News: Wednesday, December 14, 2022
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, December 14, 2022
Denouement: Congress Fails to Act by December 16, a New Continuing Resolution Goes to December 23, Then Gridlock
InsideHealthPolicy reports on the end of the 117th Congress. “House lawmakers are gathering bipartisan support to avert the impending Medicare physician pay cuts and the GOP Doctors Caucus has offered to work with leadership to avert the upcoming cliff, but one lobbyist worries the stalled omnibus talks could be the start of health care gridlock and presage the inability of lawmakers to legislate going into next year.”
“Physicians are facing a slew of pay cuts in 2023, including the 4.5% conversion factor cut under the 2023 physician fee schedule, clinical labor policy cuts and cuts tied to the PAYGO scorecard from the American Rescue Plan, as well as the end of the 5% bonus for those in alternative pay models. Providers have been on edge with talks of a continuing resolution growing as omnibus discussions stall.”
“A new stopgap continuing resolution (CR) is expected, as work will not be completed by the current CR’s December 16 expiration, a Dec. 9 McDermott+ analysis says.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Patient Satisfaction Surveys: Potential for Harm to Both Patients and Clinicians
The surveys once more attract negative attention, in a “Viewpoint” published in JAMA (here). “Forcing physicians to compete for bonus payments under a topped-out measure such as CG-CAHPS induces stress and burnout. This is not a criticism of valuing patient satisfaction as a priority nor a criticism of using survey methods to assess patient satisfaction; it is a statement about the failure of a specific measurement system.”
In addition, “Professionals or their consultants learn from or engineer efforts to boost measured performance. This sets off a competition for the best-resourced individuals to drive metric-based performance, often with exacting focus on factors wholly insignificant to physiologic health but potentially useful in climbing up the percentile ladder. In other words, scores can be improved with ever-greater investment of resources even if no meaningful clinical benefit is achieved. This counterintuitive result comes from a failure to retire metric-based assessments when they are no longer able to provide meaningful information for clinical care.” (Italics added.)
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
For-Profit Hospital Margins Increase, Overshadow Financial Plight of Smaller Non-Profits
FierceHealthcare reports that “Operating margins for the three largest for-profit hospital chains exceeded pre-pandemic levels in the third quarter, according to a new analysis that comes as hospital lobbies are pushing for financial relief from Congress . . .The analysis, released Monday by the Kaiser Family Foundation [here], looked at the latest financial performance for large hospital chains HCA Healthcare, Tenet Healthcare and Community Health Systems.”
“As of the third quarter of 2022, operating margins were 11.4% for HCA, 8.4% for Tenet and 1.2% for CHS.” In addition, the stock prices for the three hospital systems increased during the first year and a half to two years of the pandemic. “At their heights, HCA stock prices had increased by 87.9%, Tenet stock prices had increased by 153.8% and CHS stock prices had increased by 383.1% relative to January 2020.”
Private Right of Action at Risk in Nursing Home Suit Before Supreme Court
Nicole Huberfeld discusses (in JAMA, here) the role of §1983 suits in monitoring and enforcing the rights of Medicaid beneficiaries and providers, especially in the face of indifferent or hostile State actions. The question is “[M]omentous for physicians and other clinicians who treat Medicaid patients and anyone else who is reliant on federal social programs administered by states. The Department of Health and Human Services does not have enough money or personnel to closely track whether states are complying with the Medicaid Act, so private lawsuits serve the purpose of alerting the federal government to hold states accountable.”
She adds, “Federal agencies often cannot know when states run afoul of federal law unless someone on the ground experiencing the deprivation seeks a hearing. Otherwise, states could get away with violating federal law with few repercussions, to the detriment of clinicians, health care facilities, and patients. The ability to hold nursing homes accountable for substandard care hangs in the balance.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Medicaid in 2023
MACPAC gave a preview of its recommendations for 2023 during its December 8-9 meeting (agenda here). The advisory group to Congress considered the adequacy of payment to various Medicaid providers, and related issues.
Highlights from the 2022 edition of MACStats (here) begin by noting that, in 2021, almost 30% of the U.S. population was enrolled in Medicaid (87.8 million) or CHIP (8.6 million) for at least part of the year. Excluding federal funds, Medicaid made up almost 15% of the budgets of the States in 2020, compared, for example, to 25% for elementary and secondary education. Medicaid accounted for 17% of national health expenditures, compared to 20% for Medicare.
Seventy per cent of Medicaid enrollees are in “managed Medicaid,” accounting for fifty percent of Medicaid expenditures. Five per cent of enrollees use Long Term Services and Supports, accounting for a third of Medicaid spending. Drug rebates cut the Medicaid drug bill in half. And the so-called supplemental Medicaid payments to hospitals, including DSH (Disproportionate Share Hospital) and UPL (Upper Payment Limit), accounted for half of all payments to hospital in the Medicaid fee-for-service programs.
Specific subjects discussed at the meeting include program flexibility for “in-lieu-of” services under Medicaid (e.g., providing meals to avoid ED visits or hospitalization), here; and how to move Medicaid drug coverage (statute currently mandates that Medicaid cover every drug as soon as approved by the FDA) to a system more like Medicare or exchange drug coverage (which allows exclusion of some drugs, and 90 to 180 days to make coverage decisions).
Medicaid DSH Program Reviewed
The Medicaid DSH program of payments to hospitals (see above) had its annual review (here) at the December 8-9 MACPAC meeting. The DSH payments, required to offset uncompensated care for Medicaid-enrolled and uninsured individuals, are made both through State and Federal allotments. State DSH payments are limited by the Federal allotments which were based on FY 1992 DSH spending, and which are scheduled to be reduced in the fiscal year beginning October 1, 2023. (Such reductions have been regularly scheduled, then voided, since passage of the Patient Protection and Affordable Care Act in 2010. The scheduling takes place as a theoretical offset to a decline in the number of uninsured. The voiding takes place as uncompensated care continues to be a significant financial problem for hospitals, especially in safety net areas).
Twenty-seven million individuals remained uninsured in 2021, and fifteen million Medicaid beneficiaries could lose their coverage—added during the Public Health Emergency—when the PHE ends.
Notwithstanding the aggregate import of DSH allotments to hospitals generally, “MACPAC continues to find that DSH allotments share no relationship with measures of need before or after [PPACA planned] reductions.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
December 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