DCMedical News: Monday, Sept. 24, 2018
DCMedical News
Washington, D.C.
Monday, Sept. 24, 2018
DCMedical News is published every day either the House or the Senate is in session. Subscription information is below.
THE BIG STORY TODAY IN HEALTH CARE:
Judge Kavanaugh’s hearing is set now for Thursday. The House returns tomorrow with four legislative working days remaining before the end of the current fiscal year. The House is expected to pass an $854 billion Defense-Labor-Health and Human Services appropriations bill, with a continuing resolution to fund other government departments until December 7.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
MACPAC Debates Hospital Payment Policies: MACPAC, the Medicaid and CHIP Payment and Access Commission, debated Medicaid payment policies to hospitals at its September 13 meeting. Medicaid managed care is the largest source of such payments, 47% of the total. Fee-for-service Medicaid makes up 26% of the total payments. The remaining 27%, the “Supplemental payments,” consist of DSH (see below), 10%; UPL or upper payment limit payments, 9%; uncompensated care pool payments, 5%; DSRIP or Delivery System Reform Incentive Payments, 3%; and graduate medical education, 1%.
MACPAC staff indicated (slides here) that they were embarking on a survey of how states target payments to particular types of hospitals, and what changes states plan to make in hospital payment policies in the future. Five states were chosen for analysis of payments, and illustrate the wide variation in state policies; in Arizona, for example, DSH amounts to 5% of total payments, but in Louisiana DSH accounts for 41%. Three of the five study states recently converted inpatient payment methods from per diem to diagnosis-related groups (DRGs), notwithstanding that Medicare has used DRGs since 1983. Other findings: “The availability of financing for the non-federal share of Medicaid payments has affected states’ use of base and supplemental payments. The use of Medicaid managed care has not substantially affected Medicaid payments to hospitals. The adoption of prospective payment systems and value-based payment models is slow.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
MedPAC Comments on OPPS Proposed Rule: In a letter (here) dated September 21, the Medicare Payment Advisory Commission commented on CMS’ proposed rule on proposed changes to the hospital Outpatient Prospective Payment System. A summary of the major provisions of the proposed rule is found on pgs. 2-3, followed by comments on each section.
MEDICAID has DSH Options: MACPAC faces policy changes and options which will affect DSH (Disproportionate Share Hospitals) payment distributions. MACPAC discussed changes in DSH fund distribution at its meeting September 13 and reviewed staff slides (here). Medicaid DSH payments are intended to offset hospital uncompensated care, including the shortfall in Medicaid payment for hospital services, as well as the unpaid costs of care for the uninsured. States have flexibility in the distribution of DSH payments; all state allotments were anticipated to be reduced under PPACA, whose sponsors assumed that the amount of uncompensated care would decrease as a result of coverage expansion. However, nearly 30 million Americans remain uninsured for health care (down from 50 million before PPACA), and nineteen states did not originally expand Medicaid. In March of 2018 a court decision changed the definition of “Medicaid shortfall.” Under the new meaning DSH payments may double, resulting in increases and/or redistribution of DSH money, by hospital. Policy could be aim to (a) raise the minimum eligibility criteria for hospitals to receive DSH payments, or achieve the same goal by (b) changing the definition of uncompensated care, for example by including the costs of care received by patients outside of the hospital setting. MACPAC intends to advise Congress on options before January, 2019.
DRUGS AND DEVICES
DoJ on the CVS-Aetna Merger: Healthcare Finance News reports (here) that the Department of Justice is holding up the proposed $69 billion merger of CVS Health and Aetna pending their agreement to divest some of the Medicare Part D plans. Currently CVS has 6 million Part D members, UnitedHealth has 5.6 million, Humana 5 million, Express Scripts 2.5 million and Aetna 2.2 million. DoJ has previously approved the $67 billion “vertical” acquisition of Express Scripts by Cigna, and has blocked “horizontal” mergers of Aetna and Humana and Anthem and Cigna.
Transcatheter Mitral Valve Clip: Research reports (NEJM here, New York Times here) that “Among patients with heart failure and moderate-to-severe or severe secondary mitral regurgitation who remained symptomatic despite the use of maximal doses of guideline-directed medical therapy, transcatheter mitral-valve repair resulted in a lower rate of hospitalization for heart failure and lower all-cause mortality within 24 months of follow-up than medical therapy alone.”
Over-the-Counter Birth Control: From Sermo, 9-23, “Oregon, California, Colorado, Washington, New Mexico, Hawaii, Tennessee, Maryland, and Washington, D.C now allow women to obtain birth control without a doctor's prescription. Pharmacists will be able to prescribe them instead. CA, MA, and D.C. are also providing a 12-month supply at a time and requiring insurers to cover the entire cost.”
READING AND REFERENCE
MACPAC Meeting Transcript (here): The complete (334 pg.) transcript of the September 13 MACPAC meeting, including discussion of multistate collaboration, development of hospital payment policies, Medicaid coverage of new and high-cost drugs, and DSH (see above). The Friday (September 14) session was canceled due to Hurricane Florence.
MACPAC on State Requirements and Options for Premium Assistance (here): “Under premium assistance programs, states have the option to use Medicaid funds to purchase group health coverage (e.g., employer-sponsored insurance) or non-group coverage (e.g., exchange plans). States may not offer premium assistance for high-deductible health plans, or flexible savings arrangements.”
References: Title XIX (here) of the Social Security Act, and Title XXI (here), the Medicaid and CHIP statutes. In addition to the updated statutes, these documents contain an abbreviated legislative history for each program, and three pages of acronym definitions (!)
EVENTS & MEETINGS
Sept. 25
3:30 p.m., Senate HELP Committee, “Health Care in Rural America: Examining Experiences and Costs.”
Sept. 26
8:30 a.m. to 4:00 p.m., Medicare & Medicaid Programs, and Other Program Initiatives, and Priorities; Meeting of the Advisory Panel on Outreach and Education. Registration required, information at https://www.regonline.com/apoe2018sept26meeting, notice and background here.
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.
Sept. 27
10:00 a.m., Senate HELP Committee continues hearing on costs, this hearing focusing on innovation, witnesses Dr. Lee Gross (Docs 4 Patient Care Foundation, Epiphany Health Direct Primary Care; Cheryl DeMars (The Alliance, Madison, WI); Dow Constantine (Executive of King County, Seattle); Dr. Jonathan Perlin, CMO, HCA, Nashville).
Oct. 25
1:00 to 5:00, “Top Minds,” Chernew, Dafny and more, “Disrupting the Health Care Landscape: New Roles for Familiar Players,” NEJM Catalyst webinar, https://join.catalyst.nejm.org/events, also sign up for “New Marketplace Survey: Payers and Providers Remain Far Apart,” which reports (here) that “health care stakeholders are not working together to achieve value-based care, but instead are waiting on government regulators to change the payment model – including, possibly, single-payer health care.”
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: 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