DCMedical News: Wednesday, Sept. 12, 2018
DCMedical News
Washington, D.C.
Wednesday, Sept. 12, 2018
DCMedical News is published every day either the House or the Senate is in regularly scheduled session.
THE BIG STORY TODAY IN HEALTH CARE:
Texas v. U.S., Ruling Expected This Week: The attack on PPACA’s individual mandate by 20 states will be the subject of a ruling by Texas federal district judge Reed O’Connor this week. Defense of PPACA came through briefs from organized medicine (here), hospitals (here), insurers (here), a group of public health scholars (here). More direct action: a new TV ad from West Virginia Senator Manchin (The Hill, here) shows him shooting a copy of the lawsuit, which is backed by that state’s attorney general, Manchin’s Republican opponent.
In the Senate: Conference coming with the House on the FY2019 health (and combined defense) appropriations, which passed the Senate August 23, 85-7. In the Senate version: more money for emergency preparedness, maternal and child health, opioids, health workforce, rural health. Less or the same amount of money for much of CDC and HRSA, nothing for public health research on firearm morbidity and mortality prevention, or for CDC’s racial and ethnic approaches to community health. Deadline for government “shutdown”: September 30, the end of FY2018.
In the House: A proposal to postpone or repeal parts of PPACA (delay employer mandate, Cadillac tax, and redefine “full-time” worker to 40 hours per week through HR 3798 here) will cost $51.6 billion over 10 years, says the CBO (here).
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Medicare Clinician Payment: OK for now, says MedPAC: A “mandated report” on clinician payment which will be a chapter in the June 2019 report of MedPAC to Congress was previewed (slides here) at the MedPAC meeting September 6. The presentation noted spending per beneficiary annual change plummeting 2012-2017, negative in 2013 and 2016 (slide #6). Cumulative volume growth from 2000 to 2016 was over 80% for tests, 70% for imaging, 40% for E&M and major procedures (slide #8). The “compound annual growth rate” in clinicians billing Medicare was 2% (2009-2016) for primary care physicians, over 10% for APRNs and PAs. Access to care for Medicare beneficiaries remains “comparable to or better than access for the privately-insured,” despite finding that “private insurance prices for clinician services are much higher than Medicare and have grown much more rapidly over the past decade” (slide #10). MedPAC-sponsored telephone surveys show “The share [of insureds] facing a problem obtaining a new primary care doctor in 2017 is 2.5 percent for Medicare and 4.4 percent for private.” There was “little evidence that higher payments translate directly to higher quality in the clinician sector” because the “Medicare current quality program for clinicians [is] granular, burdensome, not comparable across clinicians, unlikely to be successful.”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Unified Payment System for Post-Acute Care: MedPAC previewed a proposal (slides here) September 6. The presentation summarizes current post-acute expenditures and volume (slide #3), proposes a new system by 2021 and summarizes physician and nursing requirements in current settings (slide #7). It describes a proposal for two “tiers” (general, highly-specialized) of care (the latter to include ventilator, stroke, and complex medical patients). A “three-day stay” would be required for all post-acute care, mitigated by allowing observation days to count and financial risk-bearing ACOs to waive.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Do Accountable Care Organizations save money? Not enough, says CMS, who wants more of them to absorb “risk.” Plenty, says the ACO national association, with a new study by Dobson | DaVanzo (here). Why the difference? (Actually, a “difference-in-difference.”) Says the ACO organization report:
“The Centers for Medicare & Medicaid Services (CMS) calculates savings based on a benchmarking methodology where actual spending is compared with targets based on each ACO’s historical spending trended forward using the national average rate of growth in Medicare spending per beneficiary. Researchers have found that this method systematically understates the actual savings generated by MSSP ACOs . . . We estimate that ACOs in the MSSP generated savings of $1.84 billion during performance years 2013-2015, or nearly twice the $954 million in savings estimated by the CMS benchmarking methodology . . . Indeed, when independently evaluating both the Pioneer ACO and Next Generation ACO programs, CMS contractors used a difference-in-differences regression approach to estimate savings rather than the CMS benchmarking methodology . . . [which] produces a biased estimate of program savings when compared to what may have occurred if the ACO program had not been in place.”
Medicaid State Director Survey: The National Association of Medicaid Directors survey of State program directors (here) reveals that they are beleaguered (political pressure, public scrutiny), short-tenured (median tenure 26 months, with 36 gubernatorial elections taking place this fall), and heavily dependent on outside contractors.
Commercial Health Insurance Analysis: HCCI (with data from Aetna, Humana and UnitedHealthcare) has a new web site (https://www.healthcostinstitute.org/), gathering information now on 50 million commercially insured lives. Sample from a paper earlier this year (here) by Cooper and Gaynor: “Prices at monopoly hospitals are 12 percent higher than those in markets with four or more rivals. Monopoly hospitals also have contracts that load more risk on insurers (e.g. they have more cases with prices set as a share of their charges). In concentrated insurer markets the opposite occurs – hospitals have lower prices and bear more financial risk.”
PHARMA
Step Therapy Opposed by AMA: In a letter to CMS (here), the AMA and more than forty physician specialty societies expressed opposition to allowing Medicare Advantage plans to use “step therapy.” They write: “[W]e have serious concerns about CMS’s recent notification to Medicare Advantage plans that they will no longer be prohibited from utilizing step therapy protocols for physician administered drugs covered under Medicare Part B beginning in 2019. We find the growing trend towards the use of restrictive and burdensome utilization management tactics by payors concerning and urge CMS to reconsider its stance on this critical patient care issue. Step therapy protocols that require patients to try and fail certain treatments before allowing access to other, potentially more appropriate treatments can both harm patients and undercut the physician-patient decision-making process.”
Hospitals Sue Again (complaint here) to compel 340B Regulations: CQ reports that the American Hospital Association, the Association of American Medical Colleges, America’s Essential Hospitals and 340B Health are suing HHS for delaying regulations that would “require drug companies to disclose the maximum price charged to hospitals in the program. The regulations — which have been delayed five times — would also lay out penalties against companies that overcharged providers.”
EVENTS & MEETINGS
Sept. 12
9:00 a.m., Maternal and Infant Health Summit, Washington Convention Center, information at https://dcmaternalhealth.com/summit/.
Sept. 13
9:30 a.m. to 4:15 p.m., continuing September 14 9:30 a.m. to 11:45 a.m., MACPAC, the Medicaid and CHIP Payment and Access Commission, at Reagan/ITC, highlights here.
1:15 p.m. (Rayburn HOB), Energy & Commerce Subcommittee on Health holds a hearing on “Examining Barriers to Expanding Innovative, Value-Based Care in Medicine.”
Sept. 14
9:15 a.m. House Energy and Commerce Committee’s Health Subcommittee holds a hearing (in 2322 Rayburn HOB) on “Better Data and Better Outcomes: Reducing Maternal Mortality in the U.S.,” with focus on H.R. 1318 which would create grants to improve reporting of maternal health outcomes.
Sept. 18
Noon, Families USA, “What’s at Stake for Medicaid in 2018 Elections,” conference call with focus on Nebraska, Utah, Idaho, information at press@families.usa.org
Sept. 26
9:00 a.m. to 4:00 p.m., continuing September 27, meeting of the National Advisory Council on Nurse Education and Practice. Details 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
September publication dates: 13, 14, 17, 18, 20, 21, 24, 25, 26, 27, 28.
October publications dates: 1, 2, 3, 4, 5, 9, 10, 11, 12, 15, 16, 17, 18, 19, 22, 23, 24, 25, 26
November publication dates: 13, 14, 15, 16, 26, 27, 28, 29, 30
December publication dates: 3, 4, 5, 6, 7, 10, 11, 12, 13, 14
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com