DCMedical News: Thursday, December 6, 2018
DCMedical News-DCMN
Washington, D.C.
Thursday, December 6, 2018
DCMedical News is published every day either the House or the Senate is in session.
THE BIG STORY TODAY IN HEALTH CARE
AHA, AAMC, Hospitals Sue to Void Site-Neutral Reimbursement: The industry suit (here, statement here) has this central issue: “In the Medicare statute, Congress has laid out a clear distinction between ‘excepted’ off-campus PBDs [Provider-Based Departments], which meet specified grandfathering requirements, and ‘nonexcepted’ off-campus PBDs, which do not. The statute makes clear that services provided at excepted and non-excepted off-campus PBDs should be paid pursuant to different payment systems. 42 U.S.C. § 1395l(t)(21)(C). And yet the Final Rule effectively abolishes any distinction between excepted and non-excepted entities by subjecting them both to the same payment system and rate.”
According to the suit, “Mercy Health Muskegon [a Catholic non-profit system which is one of three hospital plaintiffs] operates 27 off-campus PBDs, 25 of which are excepted PBDs. These include a sleep center, a comprehensive breast high-risk clinic, specialty clinics (including neurosurgery, cardiology, geriatrics, and gastroenterology), and a number of primary care facilities capable of providing xray, laboratory, and pharmacy services in the same building.”
Hospital outpatient rates grew significantly after 1983 (with the introduction of payment limits on inpatient services through case-rate or the Diagnosis Related Group Inpatient Prospective Payment System) until 1997, with the introduction of the hospital Outpatient Prospective Payment System (part of that year’s Balanced Budget Act, implemented in 2000). Since that time hospital acquisition of physician practices has been partially financed through “capitalization” of the “site of service differential,” and “facility fees” added on to physician professional service fees. The CMS position, as stated in the suit, is “To the extent that similar services can be safely provided in more than one setting, we do not believe it is prudent for the Medicare program to pay more for these services in one setting than another.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Doctors Prepare for January 1, Part 1: The final rule for Physician Fee Schedule (PFS) brings complex change for medical practice. This is the first of three parts summarizing those changes. The Medical Group Management Association notes these highlights: (1) Conversion factor: the 2019 PFS conversion factor is set at $36.0391. The Anesthesia conversion factor is $22.2730. (2) New services: payment for communication services delivered remotely. (3) Coding: CMS defers changes to the coding and payment structure for evaluation and management (E/M) services until CY 2021. Beginning that year, CMS collapses E/M office visit levels 2 through 4 for established and new patients, while maintaining payment for level 5 visits. (4) MIPS and APMs final rule: “Clinicians and groups must use 2015-certified EHR technology when reporting for Promoting Interoperability and for participation in an Advanced APM. Cost measures count toward 15% of the MIPS final score – an increase from 10% in 2018. Only 165,000 to 220,000 eligible clinicians are expected to become qualifying APM participants in 2019, meaning they are exempt from MIPS and eligible for a 5% bonus. In the aggregate, APM bonuses are expected to total about $600-$800 million for the 2021 payment year.”
One Hundred Years: JAMA reprints this week (here) an essay from December, 1918, on the future of the medical profession, with reflections on society, as well. On doctors: “The physician is overworked and underpaid, and the influence of the profession as a whole in public affairs seems to be practically nil, even when they relate to matters with which the medical man should be the most competent to advise.” On society and medical care: “[N]o lasting improvement can be hoped for that does not take into consideration the community as a whole. It is a problem of society, not simply a problem of a class. The analysis of the deplorable conditions of the profession does not go deep enough into the causes, and unless the causes are recognized and remedied, little permanent improvement will result.”
HOSPITALS AND OTHER HEALTH CARE FACILITIES
Long-Term Care: Patients Beware: The Office of Inspective General of the Department of Health and Human Services has published a report (here) summarizing the national incidence of “adverse events” among Medicare beneficiaries in long-term care facilities. In 2010, OIG found that 27% of Medicare beneficiaries in long-term care hospitals had such events. In subsequent years, OIG found that 33% of Medicare beneficiaries in skilled nursing facilities also suffered adverse events, as did 29% of Medicare beneficiaries in rehabilitation hospitals.
An Invitation to More State Regulation: Highmark and UPMC (facing a 6-30-2019 end to consent decrees which have protected patients enrolled in either’s health plans) both invite further state action, according to an editorial (here) in the Pittsburgh Post-Gazette. “Some divorces become so bitter that the children are totally forgotten. The Pennsylvania Insurance Department and the state attorney general’s office need to keep watch over this separation. The combatants cannot police themselves and long ago, in the war to destroy each other, lost sight of the sick people who need them.”
DRUGS & DEVICES
Taking Their PBM (Caremark) Off the Price “Hot Seat”: Reuters (here) reports that CVS will offer a prescription benefit option guaranteeing its health plan clients 100 percent of any rebates, discounts or other fees paid by drug makers. The plans may then choose (or not) to offer lower prices to their enrollees. The effort will begin with group plans, may extend to government plans, as well. Says the Reuters report, “The ‘guaranteed net cost’ option could also deflect growing criticism that pharmacy benefit managers (PBMs) reap gains off the widening gap between pharmaceutical list prices and their lower net cost after hefty rebates paid by drug makers to secure coverage and access to their products.”
ICER Looking for New Members: Sign up here, for America’s “volunteer NICE.” “The Institute for Clinical and Economic Review is an independent non-profit research institute that produces reports analyzing the evidence on the effectiveness and value of drugs and other medical services.” Health plans increasingly rely on or cite ICER in their drug coverage decisions, drug makers may one day follow with some pricing decisions.
READING & REFERENCE
In Candide’s Garden: From the New England Journal of Medicine, “Dr. Sahib,” (here); “Getting Rid of Stupid Stuff,” here; “Case Studies in Social Medicine,” structural problems and forces, here.
EVENTS & MEETINGS (Events Newly Added to This List Noted in Bold)
Dec. 6
9:00 a.m., to 5:45 p.m., MedPAC, 1300 Pennsylvania Avenue, agenda here.
9:30 a.m., Bipartisan Policy Center, “Bipartisan Leadership in Health Care: Chronic Care Act of 2018,” with Senators Hatch, Wyden. Register at https://bipartisanpolicy.org/events/bipartisan-leadership-in-health-care-chronic-care-implementation.
1:00 p.m., The Commonwealth Fund releases a state-by-state report, "The Cost of Employer Insurance is a Growing Burden for Middle Income Families,” conference call briefing, information at 301-280-5739, malexander@burness.com.
2:00 p.m. Business Roundtable CEO Innovation Summit: “America: The Innovation Nation.” 901 Wharf St., SW, Washington, Contact: Rayna Farrell rfarrell@brt.org, Agenda and Speakers here.
Dec. 7
8:00 a.m., to Noon, MedPAC, 1300 Pennsylvania Avenue, agenda here.
Noon, Alliance for Health Policy, “Aging in America,” information at 202-789-2300 info@allhealthpolicy.org
Dec. 10
The American Bar Association (ABA) holds the 16th annual Washington Health Law Summit, December 10-11, information at 202-662-1090 at 202-662-1000, registration at https://www.americanbar.org/events-cle/mtg/inperson/332144284/.
12:30 to 5:00 p.m., PTAC (Physician-Focused Payment Model Technical Advisory Committee) meeting, shortened to one day, Federal Register notice here.
Dec. 11
2:30-4:00 p.m., Bipartisan Policy Center, Financing Public Health Infrastructure, panel, 1225 Eye Street NW, Suite 1000, Washington, 202-204-2400
Dec. 18
First meeting, the HHS Deputy Secretary’s Innovation and Investment Summit. Program announced, here; participants selected, list here; FAQs 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), 2019 House Calendar (here).
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
December publication dates: 7, 10, 11, 12, 13, 14
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com