DCMedical News: Tuesday, October 9, 2018
DCMedical News
Washington, D.C.
Tuesday, October 9, 2018
DCMedical News is published every day either the House or the Senate is in session. To subscribe, please see below.
THE BIG STORY TODAY IN HEALTH CARE
Justice Kavanaugh joins Supreme Court beginning today: This session begins with a new Justice (NYTimes report here), confirmed 50-48, for the second week of the new term (court calendar here). Senator Collin’s speech is reprinted by The Atlantic here. The new Justice is certain to have an important impact on the health field, among others: Prof. Tim Jost commented on some likely health field controversies, here. Also, here is an excerpt (in italics) from the July 11, 2018 edition of DCMedical News:
Patient Protection and Affordable Care Act (PPACA): In Seven Sky v. Holder, (here) which presaged Chief Justice Roberts finding (NFIB v. Sebelius, here) that PPACA’s individual mandate was a tax—although only for constitutionality purposes--Judge Kavanaugh dissented as to jurisdiction and did not vote on the case merits. In that dissent, Judge Kavanaugh (at pg. 39) cited the 1867 Anti-Injunction Act. He wrote that the courts did not have jurisdiction to rule on the case, since the plaintiffs would be challenging the validity of taxes before they actually paid them, which, in the case of the individual mandate, would be in 2015. In Sissel v. HHS (here) Judge Kavanaugh supported the administration, concluding that PPACA (which raised revenue) had legally originated in the House, although the Senate subsequently struck the House text in its entirety. Some in the Senate see the Texas v. Azar challenge against PPACA’s guarantee of coverage for those with pre-existent conditions as an important pending question which will ultimately come before the Supreme Court.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Inpatient Rehabilitation Facilities Under the Microscope: Inpatient Rehabilitation Facilities, IRFs—a category of institutional health provider largely “invented” for Medicare reimbursement—are paid 2.5 times the acute care hospital rate. In turn, Medicare requires IRFs to provide intensive rehabilitation to higher severity patients. Does Medicare know what it is receiving? Not always, says the Inspector General (IG) of HHS (report here), and sometimes not at all.
In this latest report, the IG says “Our prior reviews found that some hospitals did not comply with Medicare coverage and documentation requirements for IRFs. The Centers for Medicare & Medicaid Services’ (CMS’s) Comprehensive Error Rate Testing (CERT) program found that the error rate for Medicare payments to IRFs increased from 9 percent in 2012 to 62 percent in 2016. According to the Medicare Payment Advisory Commission (MedPAC)—a nonpartisan, legislative branch agency that provides the U.S. Congress with Medicare Program analysis and policy advice—in 2013 Medicare spent $6.8 billion on fee-for-service (FFS) IRF care provided in about 1,160 facilities. In recent years, Medicare FFS has paid for the majority of the services IRFs provide.” Appendix D on the 25th page of the report shows that in 220 sample bills worth $11.3 million there were $8.3 million worth of claims for care not reasonable and necessary. At that rate, the report estimates $5.7 billion in improper payments for 2013. See Appendix E for documentation deficiency examples beginning on the 26th page of the report; MedPAC recommendations on the 34th page of the report; CMS response (August 16, 2018) beginning on the 36th page of the report.
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
AHP and STLDI News: In Iowa the Farm Bureau and Wellmark Blue Cross Blue Shield are selling “health benefit plans” under which applicants can be asked about disqualifying pre-existent conditions. (The Hill reports here, the Farm Bureau 5-year “look back” health checklist is here.)
Medicare Advantage for 2019: CMS announced (here) that MA plans will have lower premiums in 2019, and that there will be 600 more plans, or about 3,700 in total, projected to have 36% of total Medicare enrollment.
Medicare Payments for Services in Inpatient Psychiatric Facilities (IPF): MedPAC examined payment issues October 4 (here). In 2016, 1600 inpatient psychiatric facilities submitted Medicare cost reports, representing service to 272,000 beneficiaries, at a cost of $4.3 billion. The number of IPF cases declined 1.4% per year, 2004-2014, and the decline accelerated to almost 4% per year, 2014-2016.
IPF users were, on average, high users of all other Medicare services, with average annual Medicare spending on all covered services $40,294 per beneficiary, compared to $11,809 per year for all Medicare beneficiaries. Margins ranged widely: not-for-profit hospital-based IPFs lost 18.5%, while freestanding for-profit IPFs gained 29%. (Editor’s note: CMS’ definition of “margin” is most useful for comparison between facilities, but is not always consistent with the definition of “operating margin” in traditional accounting.) Approximately one third of IPF users had “potentially preventable” readmissions. Additional problems: non-reporting facilities, generally for-profit, who may be stinting on care, and inadequate post-discharge care generally.
EVENTS & MEETINGS
Oct. 10
“America’s Physician Groups” (APG) has its “Colloquium 2018” through October 12 in Washington (information here) on “The Essentials of Value-Based Care.” APG claims 300 member groups in 44 states “practicing capitated, clinically integrated care.”
Oct. 15
4:05-5:45 p.m., HHS Secretary Azar on “Affordable Medicines: Access, Innovation and the Public Interest,” at the National Academy of Medicine, Washington, DC. Additional information here.
Oct. 16
1:30-2:45 p.m., Potential Midterm Election Implications for Health Care, Alliance for Health Policy Webinar, for information contact Ann Nguyen at anguyen@allhealthpolicy.org.
Oct. 18
3:00 to 4:40 p.m. CMS Administrator Seema Verma at Brookings on Medicare Part D, followed by a panel (Kavita Patel, Samuel Nussbaum and others). Introduction: “Today, 43 million Americans have prescription drug coverage through Medicare Part D, roughly double the number since the program’s introduction in 2006. In the wake of fast-growing drug prices and the rise of specialty drugs, renewed attention has focused on reforming Part D’s benefit structure and providing plans with more tools to obtain lower drug prices. The Trump administration has issued a series of recommendations in their Blueprint to Lower Drug Prices and the president’s budget, and the administration has already begun to advance several pricing reforms through regulation.”
Information at: https://www.brookings.edu/events/a-conversation-with-seema-verma/
Oct. 19
12:00-1:30 p.m. (lunch at 11:30 a.m.), Flexibility and Innovation in Medicaid, Congressional Briefing, Alliance for Health Policy, for information contact Ann Nguyen at anguyen@allhealthpolicy.org.
Oct. 24
9:00-10:15 a.m., Health Policy in the Polls, Reporter Breakfast, Alliance for Health Policy, for information contact Ann Nguyen at anguyen@allhealthpolicy.org.
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 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.”
Nov. 8
Through Nov. 13, 2018 AMA Interim Meeting, Gaylord Convention Center, National Harbor, Maryland
Dec. 4
9:00 a.m., CMS sponsors a “Town Hall” meeting “to discuss fiscal year (FY) 2020 applications for add-on payments for new medical services and technologies under the hospital inpatient prospective payment system (IPPS). Interested parties are invited to this meeting to present their comments, recommendations, and data regarding whether the FY 2020 new medical services and technologies applications meet the substantial clinical improvement criterion.” Registration required by 11-19-2018, Federal Register notice 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
October publications dates: 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