DCMedical News: Monday, October 28, 2019
DCMedical News-DCMN
Washington, D.C.
Monday, October 28, 2019
DCMedical News is published every day both the House and the Senate are in session. Subscription information below.
THE BIG STORY IN HEALTH CARE
Four Legislative Days Remain Before Another Congressional Recess, Twelve Legislative Days Remain Until the Thanksgiving Recess, Twenty Legislative Days are Left in 2019
The Senate will remain “in session” at week’s end, but Halloween is the last day in session for the House until November 12. The Continuing Resolution funding the government expires November 21, following which there is a recess for the Senate until December 2 and for the House until December 3. Twenty days remain in 2019 during which both houses of Congress are in session, calendar here.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
A Public-Private Partnership
The AMA has announced that the recently published Medicare physician fee schedule rule contains significant (“once in a generation”) updates for the Evaluation and Management or E/M codes in the Current Procedural Terminology. “These changes were approved by the CPT® Editorial Panel this year and would be effective January 1, 2021 . . . The E/M Office Visit codes cover a large percentage of the healthcare delivered today. Since these codes haven’t had substantial changes since 1992, the impact of these changes will be far reaching.” The AMA has published initial guidance (here) and established a website (https://www.ama-assn.org/practice-management/cpt/cpt-evaluation-and-management?) to monitor implementation. A 3-M regulatory affairs blog (here) notes that “CMS mentioned during their conference call that 10,000 new beneficiaries are added daily while fewer clinicians are available to care for them. The revisions to E/M and the new reimbursement categories may be one step toward improving those ratios. Adding patients and driving clinicians out of practice does not promote quality health care. The AMA/CMS revisions make sense--potentially they will force changes in the E/M formats in the EHRs. It will be interesting to see how the EHR format is modified to accommodate the changes and how much that will cost.” Another 3-M blogger (here) summarizes other major category changes in the 2020 CPT.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Insurers and Employers Powerless to Counter Price Hikes from Hospital and Physician Consolidation
A new study from the Georgetown Center on Health Insurance Reform (blog here, study here) finds that health insurers and employers have few tools with which to counter hospital and physician group consolidation-fueled price hikes.
The study found:
“Hospitals are empire-building. Hospitals’ motivations for consolidation are similar . . . a pursuit of greater market share and a desire to increase their negotiating leverage with payers to demand higher reimbursement.
Payers have tools to constrain cost growth, but they lack the incentive and ability to deploy them effectively. While payers in our markets identified several cost containment strategies such as narrow networks and provider-payer partnerships, all come with downsides. Furthermore, some third-party administrators for self-insured employers actually have incentives to keep provider prices high when they’re paid a percentage of the overall cost of the plan.
Employers’ tools to control costs are limited. Employers are frustrated with existing strategies to reduce cost growth such as the exclusion of certain providers or higher deductibles in the face of employee dissatisfaction and limited evidence of savings. However, emerging strategies that could be more effective may be challenging for many employers to implement, and employers lack access to basic data to inform their efforts.
Public policy strategies have had limited effectiveness. Anti-trust and other policies to limit the ill-effects of consolidation have had a limited impact in our study markets, but there are nascent state-level efforts to push back on provider prices that are worth watching.”
The Georgetown group conducted “Six market level, qualitative case studies, focusing on mid-sized health care markets in which there had been recent consolidation activity,” including Detroit (here), Syracuse (here), Northern Virginia (here), Indianapolis (here), Asheville, North Carolina (here) and Colorado Springs (here).
Exchange Open Enrollment Period Begins November 1
CMS has announced (here, with links to resources) that “The Federal Health Insurance Exchange (also known as the Marketplace) Open Enrollment Period runs from November 1, 2019 to December 15, 2019, for coverage starting on January 1, 2020.”
“Somebody Has to Say It: Medicare-for-All is a Pipedream”
So says Rahm Emanuel, in the Washington Post (here). He writes, “I’m mystified as to why, at a moment when 90 percent of Americans already have insurance, our presidential debates are focused so exclusively on expanding coverage rather than containing costs. That’s the challenge that bedevils most families constructing their monthly budgets at the kitchen table.” Also on his list, “We should focus on the fastest-growing portion of the uninsured community — the vote-rich demographic of early retirees. Here’s a simple fix: Expand coverage by allowing Americans 55 and older to buy into Medicare before they hit 65,” and offer a “public option” through the existing Federal Employees Health Benefit Program.
Health Plans Due $1.6 Billion for Cost Sharing Reduction Payments
In Common Ground Healthcare Cooperative v. the United States the Court of Federal Claims entered an Order (here) to rebate $1.6 billion to a list of health plans (five pages of the Order). Bloomberg Law reported that “Insurers participating in Obamacare health insurance marketplaces, also called exchanges, agreed to reduce some of their members’ costs, such as deductibles and copays, in exchange for the government’s promise to reimburse them for the discounts. But Congress never appropriated the money to pay the insurers. In 2017, the Trump administration declared it would no longer do so.” The government can appeal the decision.
A much larger ($12 billion) amount is at stake in the “risk corridor” cases (Maine Community Health Options, Moda Health Plan, Land of Lincoln Mutual Health Insurance) which the Supreme Court has consolidated and on which it will hear oral argument December 10. The government has urged (brief, here) the Court to uphold the appeals court decision in Moda. The risk corridor provisions of the Patient Protection and Affordable Care Act directed HHS to collect payments from profitable insurers and redistribute them to insurers that lost money by enrolling sicker, previously uninsured people. However, there was no additional appropriation, and the government collected insufficient moneys from the profitable plans to fulfill $12 billion of payments to the unprofitable plans. But SCOTUSBlog (at https://www.scotusblog.com/case-files/cases/moda-health-plan-inc-v-united-states/) presents the issue as “Whether Congress can evade its unambiguous statutory promise to pay health insurers for losses already incurred simply by enacting appropriations riders restricting the sources of funds available to satisfy the government’s obligation.” Prof. Jost opines for The Commonwealth Fund, here.
U.S. House of Representatives:
Members at https://www.house.gov/representatives
Committees and Members at https://www.house.gov/committees
U. S. Senate:
Members at https://www.senate.gov/general/contact_information/senators_cfm.
Committees and Members at https://www.senate.gov/committees
House and Senate 2019 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
October publication dates: 29, 30, 31
November publication dates: 12, 13, 14, 15, 18, 19, 20, 21
December 3, 4, 5, 6, 9, 10, 11, 12
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.