DCMedical News: Thursday, July 19, 2018
DCMedical News
Washington, D.C.
Thursday, July 19, 2018
DCMedical News is published every day either the House or the Senate is in session.
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THE BIG STORY TODAY IN HEALTH CARE
Heavyweights and Change in the Air: The pay experiments of the PPACA era may be coming to an end. Some inadvertently stimulated gaming (HAI report). Some promised savings (bundles) but over-promised, see Joynt Maddox below. MIPS may be expiring, while CMS opens a controversial 1473-page rule on payment changes, parts of which pit big-group physicians against independents. The Ways and Means Committee thinks weakening Stark self-dealing prohibitions is the way forward for “value-based pay.” And now Chernew and Frakt weigh in with “Entitlement Reform” in NEJM, here. Summer!
On Hospital Acquired Infections (HAI) a new study (here) shows that financial penalties for such infections led to a significant change in hospital practice. The change was that a much larger number of patients were found to have had such infections at the time of admission (POA, Present on Admission), in which case the penalty was avoided. Part of the reason the policy did not have its intended impact is that “billing codes for CLABSI [central line-associated bloodstream infection] and CAUTI [catheter-associated urinary tract infection] were rarely used, were commonly listed as POA in the postpolicy period, and infrequently impacted hospital reimbursement.” The article offered no explanation as to how patients might have “central line infections” or “catheter-associated infections” at the time of hospital admission.
On the bundles, initial enthusiasm about the 2013ff experiment was in surgery, for joint replacement. The Joynt Maddox group reported that previous studies showed reductions in Medicare payments for total joint replacement. This new study (here) on medical bundles shows “Hospital participation in five common medical bundles under BPCI was not associated with significant changes in Medicare payments, clinical complexity, length of stay, emergency department use, hospital readmission, or mortality.” One hypothesis would be the cost of devices: surgeons can choose less expensive joints, if motivated, but medical bundles present fewer opportunities for such “economizing.”
On MIPS and payment, CMS has found that even modest change in highly scrutinized pay rates will raise significant opposition (below, under Medicare).
On value-based payment, the House Ways & Means Committee contends that major impediments to achieving value-based pay are the self-dealing prohibitions of Stark laws and the Anti-Kickback Statute.
Even on DRGs, CMS (and HCFA before CMS) has been doing it wrong, since 1983, according to Judge Kavanaugh (here).
Enter Chernew and Frakt (here), with “Entitlement Reform.” They write, “At some point, Americans will probably be unwilling to pay higher taxes or increase borrowing to fund public health care programs. Capturing this view, House Speaker Paul Ryan (R-WI) has emphasized the importance of reining in spending on such programs, stating (accurately) that ‘it’s the health care entitlements that are the big drivers of our debt.’ Specifically, growth in inflation-adjusted Medicare and Medicaid spending reflects increasing numbers of beneficiaries and growth in spending per beneficiary. The latter, in turn, reflects both price inflation (relative to general inflation) and growth in utilization per beneficiary. The importance of each of these factors has changed over time because of demographic shifts and policy actions. Current approaches to reform may therefore have to be different from past strategies.” How different? More here.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Ways and Means Sees Rolling Back Self-Dealing Rules as the Way Forward for Value-Based Pay:
The House Ways & Means Committee this week took aim at the Stark law and the Anti-Kickback Statute, labeling them as impediments to progress in achieving “value-based” pay programs. Stark prohibits doctors from referring Medicare patients to health facilities and colleagues with whom they have financial relationships. The Committee contends that Stark prevents hospitals from paying physicians more when they meet quality measures, such as reducing hospital-acquired infections (see above).
The Committee’s view was supported in testimony (here) from Deputy Secretary Eric Hargan of the Department of Health and Human Services (HHS); Dr. Gary Kirsch, President of The Urology Group (here); Mike Lappin, Chief Integration Officer of AdvocateAuroraHealth (here); Dr. Brian DeBusk, President and CEO of DeRoyal (here); and Claire Sylvia, Partner at Philips & Cohen LLP (here), a law firm representing False Claim Act whistleblowers.
"The Stark law may unduly limit ways that physicians and healthcare providers can coordinate patient care by restricting ways physicians can organize and work together and with others," Hargan said. He noted that HHS plans a rulemaking based on responses to a Request for Information (here). Another target was §6001 of PPACA, the limitation on physician owned hospitals. Rep. Sam Johnson (R-TX) addressed the Obamacare ban on physician-owned hospitals, characterized as “another component from the Democrats’ failed health care experiment that has limited patients’ access to quality care.”
Fee Trouble: CMS officials faced a storm of criticism from specialist physicians who feel that the proposed calendar year 2019 pay rule will lower their pay. In the proposed rule (here), CMS seeks to “collapse” the level 2 through 5 office codes into a single blended payment rate for new and for established patients. Subsequent to the initial publication of the proposed rule, physician specialty groups have determined that, rather than the estimated 1% to 2% cut or increase in pay, cardiologists, oncologists and neurologists would suffer a 3% cut in fees, rheumatologists 6% and endocrinologists 8%. The proposal would appear to underpay specialists who have higher “intensity” office visits.
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
California v. Trump: A federal court in California on Wednesday dismissed a case brought by 18 Democratic attorneys general challenging the Trump administration's decision last year to end PPACA's cost-sharing reduction (CSRs) payments to insurers, but the court leaves the door open for the attorneys general to refile their case if HHS moves to block the silver-loading workaround that has made up for the lack of CSRs.
Calendar Year 2019 Proposed Rules on Medicare Outpatient Pay, Quality: DCMN 7-13-2018 (here) covered the initial exposure of this proposed rule’s (here) pay provisions. Here is a summary of the “quality” provisions in the proposed rule (scheduled to be published in the July 27 Federal Register) for the third year of the Quality Payment Program (QPP).
First, Certified Electronic Health Record Technology is required in 75% (up from 50%) of claims. Second, the “certification” process is now open to all payers for the QPP program year 2020. This would allow commercial payers and other public payers such as employee benefits plans to have certified their “Other Payer Advanced APMs.” Third, the interoperability requirements attempt to align electronic clinical quality measures of Medicaid with those of the Medicare Merit-based Incentive Payment System (MIPS). A 28-page fact sheet on the QPP in this proposed rule is found here.
EVENTS & MEETINGS
July 20
12:00 p.m. – 1:30 p.m., “State Responses to the Evolving Individual Health Insurance Market,” Commonwealth and Alliance for health Policy, Dirksen SD-106.
July 25
7:30 a.m. – 4:30 p.m., Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), volume requirements for aortic valve replacements and percutaneous coronary interventions.
Maria Ellis, MEDCAC, (410) 786-0309, maria.ellis@cms.hhs.gov. Federal Register notice of meeting here, National Coverage Determination request for comment (6-28-2018) here.
Aug. 20
Meeting of Medicare Advisory Panel on Hospital Outpatient Program (through August 21), APCs, OPPS, the works. Evaluation of Advanced Primary Care (APC) groups; packaging of Outpatient Prospective Payment System (OPPS). Federal Register notice (5-3-2018), here.
Aug. 22
7:30 a.m. – 4:30 p.m., Medicare Evidence Development and Coverage Advisory Committee (MEDCAC), CAR-T cell therapies, collection of patient reported outcomes in cancer clinical studies.
Maria Ellis, MEDCAC, (410) 786-0309, maria.ellis@cms.hhs.gov. Federal Register notice (6-15-2018) here.
FOR REFERENCE
Members of the Senate (here) and Members of Senate Committees (here), Senate Calendar (here).
Members of the House with their House Committees (here), House Calendar (here).
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
DCMedical News is published every day that either the House of Representatives or the Senate is in session.
Trial subscriptions may end without notice, and all will end July 31.
July publication dates: 20, 23, 24, 25, 26, 27, 30, 31.
August publication dates: prn, Senate may be in session.
September publication dates: 4, 5, 6, 7, 12, 13, 14, 17, 18, 20, 21, 24, 25, 26, 27, 28.
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com