DCMedical News: Friday, July 27, 2018
DCMedical News
Washington, D.C.
Friday, July 27, 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:
Health Care Themes for House Members in Mid-Term Elections, District Meetings: Health legislation “themes” have emerged from the two political parties which may be highlighted during the coming campaign season. In the House, the work of the Energy & Commerce Committee has focused on HSAs and deregulation. Together with virtual “elimination of the individual mandate” and “Medicaid-for-work,” these amount to Republican themes.
Among Democratic House members, two different groups have emerged. The “Medicare-for-all” group is working toward a detailed bill and affordable budget. A “New Democrat Coalition Healthcare Task Force” is supporting H.R. 5155 (bill here, support letter here). This bill would increase the size of premium tax credits, expand eligibilities for subsidies, oppose short-term and association health plans, restore funding to the navigator program, and support universal coverage, but not single-payer for that coverage. Both of these groups (Medicare-for-all, New Coalition) have roughly equivalent numbers of House Democratic members.
The House will recess for August. The Senate is supposed to be in session in August, but there are no announced plans for legislation. Senate Majority Leader McConnell announced the August session in response to what he perceived as delay in the confirmation of federal judges, and to provide additional time within which appropriations bills may be debated. Minority Leader Schumer responded June 5 saying that the Democrats will seek votes in August on legislation to “lower health care costs.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
MIPS, MACRA and Physician Groups: The Energy & Commerce Committee heard Thursday from witnesses concerned with the Merit-based Incentive Payment System (MIPS) and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Generally, the witnesses represented “big medicine,” whose members are concerned about the disappearance of MIPS bonus funds, versus “independent medicine,” whose members have dropped out or would like to drop out of MIPS, lowering the size of the bonus pool. Also of concern was the reluctance of HHS to accept new “innovations” in payment plans offered to PTAC.
Appearing were representatives of the American Medical Association (testimony here); the American College of Surgeons (testimony here); the American Society of Cataract & Refractive Surgery (testimony here); the American Medical Group Association (testimony here); and America’s Physicians Groups (testimony here).
HOSPITALS AND OTHER HEALTH CARE FACILITIES
OPPS Proposed Rule Bad News for Hospitals: The Outpatient Prospective Payment System Proposed Rule (here) for CY2019 is widely seen as negative for hospitals, based on commentary and opinion to date.
First, the proposal extends to “off campus departments” (ambulatory care initiatives, for example, acquisition of physician practices), the 340B drug discount cuts. 340B payment is now 22.5% less than average sale price for drugs purchased through the program (compared to the previous payment rate of “average sale price plus 6%”). Also, CMS proposes to pay for biosimilars at the average sale price minus 22.5% of the biosimilar’s own average sale price, rather than the reference product’s average sale price.
Second, the proposed OPPS rule cuts rates for “clinic visits” at hospital outpatient departments by 40%, to the rate paid under the Medicare outpatient (Part B) physician fee schedule, “site neutral” payment.
Third, the Proposed Rule expands the list of allowable procedures in ambulatory surgery centers (ASCs) to include a dozen highly profitable cardiac catheterization procedures. Those procedures are CPT 93451 – 93462. Analysis by Dr. Ronald Hirsch in “RAC Monitor” (here) notes that CMS did not approve payment for cardiac interventions in ASCs; this means that if catheterization shows that a patient requires a stent, the subsequent interventional procedure must be scheduled at a hospital. This will of course increase cost to Medicare for those patients needing intervention, paying for two procedures, and is a return to an earlier era (see Nallamothu and Krumholz in JAMA, here), in which patients first had their diagnostic catheterization, then met with their physician to discuss the results and treatment options. However, it may be a short step—with pressure from the expense of two procedures—to allowing stent placement in the ASC. The only “positive” ASC-related news for hospitals is that total knee replacement and total hip replacement remain on the “inpatient only” list, that total joint replacements will not be allowed at ambulatory surgery centers in 2019. Cardiac and orthopedic procedures are widely perceived to be the most (and sometimes the only) profitable admissions for hospitals.
Separation of coronary angiography from percutaneous coronary intervention (PCI) may in fact diminish the volume of PCIs. The time gap between catheterization and stent placement (prior to what is now known as “ad hoc PCI”) provided an opportunity for evaluation of alternative medical treatment. Krumholz and Nallamothu write that “By making the diagnostic tests an automatic gateway to the therapeutic procedure, pressure is placed on the cardiologist and patient to make immediate decisions that may favor PCI even in elective settings.” (JAMA, 11-10-2010).
Finally, there are OPPS payment rates. What the government gives…it apparently takes away, in the same proposal. The OPPS rates “should” rise by 2.8% in calendar year 2019, the “market basket update.” However, there is a –.8% “productivity adjustment.” There is also a –.75% “adjustment for cuts under the ACA.” So the net looks like a 1.25% increase. But then comes the 40% reduction in clinic rates to equal the physician office rate, projected to reduce overall OPPS payments by 1.2%, and just about offsetting the 1.25% rate increase. More to come: Ten “hospital quality reporting program” measures are removed in the proposed OPPS rule, one measure in 2020, the others for 2021.
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
Medicaid Growth May Be Skewed Toward New Enrollees: An opinion piece in the Wall Street Journal (here) contends that PPACA provides incentives to states to spend more Medicaid funds on new enrollees. This means that the states have less to spend on medical care (under Medicaid) for the “categorically eligible,” for example, Aid to the Permanently and Totally Disabled. The WSJ notes that the federal share of Medicaid is between 50% and 76% for enrollees prior to PPACA, but 95% for the expansion population, also typically more profitable for insurers running managed Medicaid programs.
AHPs: A dozen Democratic attorneys general sued the Department of Labor over the new rules for Association Health Plans. The suit (here) contends that AHPs unlawfully skirt the gender, age and benefit provisions of PPACA.
PHARMA
GAO Analyzes “Charity Care” by 340B Hospitals: The Government Accountability Office (report here) found that hospitals eligible for the Section 340B drug discount were no more “charitable” than non-340B hospitals, but that the 340B hospitals qualifying on the basis of the Disproportionate Share Hospital (DSH) percentage and also Sole Community Hospitals provided more charity care. GAO reported further than the number of hospitals participating in the program increased by 60% in the five years before 2016, primarily among hospitals that first became eligible (Critical Access Hospitals, freestanding cancer hospitals, rural referral centers, Sole Community Hospitals) through PPACA. DSH hospitals constitute 45% of those in the 340B program. The advocacy group “340B Health” has reported that nearly three-quarters of its rural hospital members say their 340B savings on drug purchases are the difference between staying in business and closing.
EVENTS & MEETINGS
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. Subscribe now, avoid interruption of service.
July publication dates: 30, 31.
August publication dates: prn, Senate may be in session, but no legislative activity is planned.
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