DCMedical News: Friday, February 7, 2020
DCMedical News-DCMN
Washington, D.C.
Friday, February 7, 2020
DCMedical News is published every day both the House and the Senate are in session.
THE BIG STORY IN HEALTH CARE: DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Moral Injury and the Business of Medicine
The Washington Post (here) describes the work of Dean and Talbot on moral injury among medical practitioners. “The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans’ hospitals, refers to the emotional, physical and spiritual harm people feel after perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” With Arthur Caplan, the two researchers discuss the vocabulary of physician burnout, here, in JAMA.
A Pain in the Back
The Economist, which recently dubbed American hospitals a “racket” (here), has taken aim at another domestic institution, back pain (here). “The medicalisation of back pain sees huge amounts spent on treatments of little if any benefit to patients.” Scanning? Doctors routinely ignore caution, “sending 40-60% of people with back pain to be scanned-far more than they did 20 years ago,” when “there is a broad consensus that about 80% of such scans are useless.” Surgery? “In 2011 Cigna, an American insurance company, ran a follow-up study on patients who had undergone procedures in which vertebrae are stitched together with implanted bolts and braces. ‘Spinal fusion’ of this type is a frequently used surgical response to back pain that is associated with the degeneration of spinal discs; in 2015 there were roughly 85,000 such surgeries in America. The company found that two years after treatment 87% of customers were still in pain severe enough for medication or some other treatment; 15% had more surgery.”
A big problem, according to the paper: “If a therapy has been accepted by an insurance company, or a government scheme like America's Medicare, it is very hard to get it removed, even if evidence for effectiveness persistently fails to turn up. ‘Once they are in, it is hard to take them out,’ says Dan Cherkin from the Kaiser Permanente Washington Health Research Institute.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Vendor-Hospital Group Lobbying Against Interoperability
Epic’s chief executive has gathered 60 prominent hospital clients (Becker’s report here, CNBC report with list of hospitals and health systems here) to oppose health information interoperability rules proposed by the Department of Health and Human Services. HHS Secretary Alex Azar denounced “scare tactics” being promoted by Epic and its allies.
One key provision in the rules would allow patients to have access to their own health data using apps. Private apps are not held to the same privacy standards as providers and payers, according to Epic. A second issue is that the attractiveness of major IT systems and one of the key sales points is the lack of interoperability, that is, the guarantee that a hospital or health system buying Epic could thereafter control access to information by its captive physician groups. The standardized application program interfaces (APIs) called for in the HHS proposal would ease access for providers and patients to exchange health data, but loosen the grip of health systems on that data.
Physicians are generally on the other side of this issue, including the American Academy of Family Physicians, the National Association of ACOs, and more than two dozen other physician groups. Apple and Microsoft have also voiced support for the proposed interoperability regulations, urging that they be implemented.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
February 5 Medicare Advantage Proposed Rule, 895 Pages, Lots of Highlights
The proposed rule (here) aspires to achieve lower drug costs for Medicare Advantage beneficiaries, increased payments for those plans, and to rework the much criticized Medicare “star” ratings.
The pay increases for 2021 and 2022 for the Medicare Advantage (MA) and Part D (drug) plans call for increases lower than those taking place this year, for example, less than 1% for 2021 for MA plans, compared to more than 2.5% this year.
In the star rating category, CMS plans to increase the weights for patient experience and complaints, as well as access measures. Patient experience as measured in the most recent CMS information has definitely produced “winners” (top hospitals for patient experience in the nation, here) and “losers” (patients felt not respected by doctors and staff), here. As in past years, most of the highly rated (93% or more of patients would recommend them) hospitals were physician-owned or single specialty hospitals, in cardiac and orthopedic specialties, as well as privately owned surgical hospitals, creation or substantial expansion of which was forbidden by §6001 of the Patient Protection and Affordable Care Act. The AHA, FAH and state hospital associations lobbied strongly against such for-profit, physician-owned hospitals.
As previously announced, the proposal rule would also allow Medicare eligible individuals with end-stage renal disease to enroll in MA plans, effective beginning 2021. Previously, MA plan beneficiaries who developed end-stage renal disease could remain in those plans. MA plans have expressed concern that enrollment by ESRD patients will increase plan costs, notwithstanding the additional money paid to MA plans based on “risk adjustment” calculations.
Part D plans would be allowed to create a preferred or specialty tier, with lower cost-sharing. Comments can be made, by March 6th.
State Action
Connecticut’s Governor has issued two Executive Orders (here and here) addressing health costs and quality. One instructs the State’s Office of Health Strategy (part of the Department of Health, formerly an independent commission) to create a health care cost containment strategy, with benchmarks through 2025 setting annual targets for increases in primary care spending as a percentage of total health care expenditures, with a goal of 10% by 2025. Reports, development of quality benchmarks applicable beginning 2022, and Medicaid cost and quality metrics are also called for.
The National Academy for State Health Policy (here, in Modern Healthcare) is developing model legislation for 2020.
DRUGS AND DEVICES
Antibiotics Prescribing Overdone in Uncontrolled Ambulatory Settings
A study in Health Affairs (here), reports that “Large fractions of antibiotic prescriptions are filled without evidence of infection-related diagnoses or accompanying clinician visits. Current ambulatory antibiotic stewardship policies miss about half of antibiotic prescribing.” Medicaid is a particular challenge: “Our evaluation of hundreds of millions of antibiotic prescriptions dispensed to Medicaid recipients revealed an alarmingly high proportion of prescriptions that were not infection related or visit based.”
READINGS AND REFERENCES
U.S. House of Representatives:
Members at https://www.house.gov/representatives
Committees and Members at https://www.house.gov/committees
U. S. Senate:
Committees and Members at https://www.senate.gov/committees
CQ 2020 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
February 10, 11, 12, 13, 25, 26, 27, 28
March 2, 3, 4, 5, 9, 10, 11, 12, 23, 24, 25, 26, 27, 30, 31
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.