DCMedical News: December 7, 2017
DCMedical News
Washington, D.C.
Healthcare, Medical Education
December 7, 2017
Time Bomb(s)
Senate Votes to Conference With House
Congress to remain in town until December 22. Big four meet with Trump today. Medicare open enrollment expires today. A Continuing Resolution (CR) to keep government funding has residual open questions but some questions are apparently closed, especially the individual mandate (gone). House takes up stopgap spending measure today (HJRes 123, Rules Committee says no amendments), Senate action needed by Friday, midnight. Rules Chair Mr. Sessions says CHIP included in the CR would allow CMS “to make states whole or allow them to be whole with federal dollars through Dec. 31, 2017.”
The Executive Order on short term policies is maturing
The Executive Order signed by Trump October 12 (Federal Register publication on October 17 found here, see section 3), requires HHS to issue a proposed rule within 60 days that allows insurers to sell two types of “skinny” plans that do not comply with ACA rules.
These plans come in two varieties, Association Health Plans (AHP) and Short-Term Limited Duration Insurance (STLDI) plans. AHPs are subject to state law if they are fully underwritten but not if they are self-insured (since ERISA, 1974). STLDIs vary by state.
EHBs?
Neither AHPs nor STLDIs are required to meet the ten ACA-specified categories - - maternity, hospitalization, drugs, etc. Unlike the ACA plans, there is no minimum “bronze” type of coverage, and the STLDIs may have lifetime limits, no minimum medical loss ratios, no preventive services without cost-sharing, no parity in mental health and substance abuse disorder, no coverage of out-of-network emergency services without prior authorization, and of course no coverage of pre-existing conditions. Pre-existent condition coverage for AHPs will vary.
MedPAC meets today (and tomorrow, Friday)
Discussing payment adequacy for ASCs, for doctors, and alternatives to MIPS (the staff is moving on, the provider members—from larger health systems, like MIPS). The Colloquy on MIPS is captured in the transcript of the November 2 meeting, found here. Also on the docket, other provider rates and an update on MA plans (doing fine, thank you).
Hospitals, Other Institutional Providers
Moody’s projects a negative outlook for non-tax-paying hospitals, the first since 2015. Spike from ACA expansion has gone, bad debt (patient responsibility!) is rising. (Moody’s Veep says bad debt rebounded in 2017, will rise 6-7% in 2018 courtesy of “consumer choice,” wait, I mean, high deductible plans.)
FQHCs possibly lost in the rush, compromised (like CHIP programs) by haste. GW/Milken study here, a sample local report here, both focus on employment losses. Employment? Don’t forget which industry produced 32,000 new jobs per month, January 2014-December 2016. New CMS report on national health expenditures says rate of spending down, but health now 17.9% of GDP). And speaking of employment, Governing chronicles decline in public employment, including in health services, report here.
Insurers, Medicaid Waivers
While Aetna bets on drug stores, UnitedHealth bets on big doctor groups. UH agreed to buy the DaVita Medical Group for about $4.9 billion. UnitedHealth's Optum will take control of DMG's nearly 300 clinics and half dozen outpatient surgical centers in six states.
Waivers: both Massachusetts and Arizona have pitched CMS to allow formulary powers in their state Medicaid programs. North Carolina proposes to pay off physician student debt in order to attract docs to Medicaid program and also to continue “wraparound” payments to compensate for low Medicaid rates.
Imperceptibly, commercial managed care has become a major influence on government programs. This month’s Health Affairs has a study on “The Big Five” insurers, increasingly dependent for growth and profit on Medicare and Medicaid. In 2016, Medicare and Medicaid accounted for 60% of their revenue. Reviewing 10-Qs will reveal that the special bump for Medicare Advantage programs accounts for most of their profit, as well. Commercial insurance for all!
Your Subscription
[This is a trial issue. The trial will continue through December 21, 2017 (or maybe December 22!). Your reaction is solicited, but not your money, at least not yet (!) Current plan: $200 per year, minimum 100 issues, refunds pro-rated for the discontented.]
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com