DCMedical News: Thursday, January 3, 2019
DCMedical News-DCMN
Washington, D.C.
Thursday, January 3, 2019
DCMedical News is published every day either the House or the Senate is in session.
THE BIG STORY IN HEALTH CARE
New Year, New Laws: The 116th Congress begins today.
House Rules: The House of Representatives will take up debate today on rules which would allow the House to intervene in Texas v. Azar. In that case Judge Reed O’Connor declared the Patient Protection and Affordable Care Act unconstitutional. Judge O’Connor reached his decision (New York Times coverage here) relying on the reduction (to zero) of the penalty for not having health insurance; the decision by the Supreme Court in 2012 that PPACA was constitutional as an expression of Congressional taxing power; and a theory that the various parts of PPACA are not “severable.” Separately, the new House Democratic caucus has scheduled a vote next week on a resolution to protect patients with pre-existing conditions.
Safe Harbors Dry Up: The medical law blog JDSupra reports that the Eliminating Kick-Backs and Recovery Act of 2018 (EKRA, here)--part of approximately 70 separate actions referred to as the SUPPORT Act, i.e. Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients in Communities Act--adds a new Anti-Kickback rule, expanding anti-kickback penalties to all health benefit programs, not only Medicare, Medicaid and TriCare, and essentially eliminating Safe Harbor protections.
Rockpointe’s Policy & Medicine reports that EKRA was intended to address the problem of “patient brokering” in drug treatment centers and sober homes. The “brokering” of patients involves an agent who enrolls an addict into a private health insurance plan, then arranges for the addict to enter a treatment facility. The facility bills a health insurance plan for services, rebating part to the agent. Because this act typically involves private pay insurance, the Anti-Kickback Statute (AKS) is not available to prosecute and stop the practice because federal healthcare dollars are not involved. EKRA will allow federal prosecutors to bring charges in connection with any patient whose care is paid for by a private health insurer. EKRA would appear to be heading in a direction opposite to the Administration, which has asked for suggestions (November 24 New York Times coverage here) from the health industry concerning new safe harbors and the elimination of barriers to “value based payment” which would otherwise appear to be kickbacks.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
GoTreatMe: Becker’s reports that GoFundMe is used to raise more than $650 million representing 250,000-plus medical campaigns annually. “GoFundMe's CEO Rob Solomon said medical fundraisers now represent 1 in 3 of the site's campaigns.” Kaiser Health News continues to explore medical expense indigency (here), finding that $100,000 per year incomes are no match for medical bills, largely due to “consumer-directed” (employee absorbs more expense) group health plans. HealthExecSnapshot reports “Gallup's annual Health and Healthcare poll once again finds 29% of Americans report they held off seeking some kind of medical treatment in the past year due to costs. This is consistent with the rate seen each year since 2005 but is up from an average 24% in the four years prior to that — from 2001-2004 — and [up] from 22% in 1991.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Physician Focus on the Care of Undocumented Immigrants: A special edition of the AMA’s Journal of Ethics, at https://journalofethics.ama-assn.org/home. Introduction: “Currently, 800,000 Deferred Action for Childhood Arrivals (DACA) recipients—including many health professionals, students, and patients—face risk of detention and deportation. Loss of DACA status could relegate many of these young people to a life marked by fear and uncertainty. This issue considers the nature and scope of clinicians’ obligations to support and care for undocumented immigrants, refugees, and asylees.”
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
An Early Christmas: CMS Administrator Seema Verma said that “Christmas came early” for Michigan and Maine, as her agency approved work requirements for Medicaid beneficiaries in those states. Seven states now have such permission. “The CMS sleigh has made deliveries to Kansas, Rhode Island, Michigan & Maine this week to drop off signed Medicaid waivers,” wrote Verma. Other states that have received the Medicaid work requirement waiver are Arkansas, Kentucky, Indiana, New Hampshire and Wisconsin, with only the Arkansas program taking effect so far, followed by coverage losses.
DSH Funding Issue Reappears: Cutbacks in the Medicaid Disproportionate Hospital Share (DSH) program are currently deferred to October 1, 2019. If not repealed or delayed further, the DSH cuts (primarily of import to safety net hospitals, those with high Medicaid and uninsured patient volumes) begin with $4 billion per year for FY 2020 (10-1-2019 to 9-30-2020), then $8 billion per year FY 2021-2025. The total DSH program now pays hospitals approximately $12 billion per year.
CQ Health reports that a spokesman for the American Hospital Association (AHA) says “The Medicaid DSH program is critical to hospitals and health systems that care for our nation’s most vulnerable populations – children, the poor, the disabled and the elderly.” However, the AHA, together with the Federation of American Hospitals and the Catholic Health Association, had agreed to a total reduction of $36 billion in DSH funds during the 2009-2010 negotiations over the terms of the Patient Protection and Affordable Care Act (PPACA). John McDonough (Inside National Health Reform, at pg. 166) noted that “hospital leaders were convinced that the revenue from the added covered lives would more than make up for their losses.” At the time, there were 50 million uninsured in the country. Now there are approximately 30 million people without health insurance. Under PPACA an estimated 20 million additional lives have been insured through health exchanges (8 plus million) and Medicaid expansion (12 million).
DRUGS & DEVICES
Drug Prices Increase for the New Year: Three dozen pharmaceutical manufacturers raised prices on hundreds of prescription drugs Tuesday, according to a study and report in Wednesday’s Wall Street Journal (here). Allergan’s chief executive noted that their increases of just below 10% were part of the company’s “social contract” with patients, notwithstanding 10% increases at the beginning of 2017 and 2018. Generic drugs (9 of 10 prescriptions filled in the U.S.) also had significant increases, especially in drugs used for pain and blood pressure control. The increases are for “list prices,” not necessarily the prices paid by purchasers. According to the Journal, “Drug makers said they raise prices in conjunction with rebates they give to pharmacy benefit managers in order to be placed on formularies.”
Advertising Drug Prices: Investment tracking service Seeking Alpha reports that four members of Big Pharma, Pfizer, Sanofi, Eli Lilly and Johnson & Johnson, generally support the inclusion of prices in TV drug ads, but caution that it needs to be done fairly. “They say that including just the list price will confuse patients since most are only responsible for co-payments. Some may not fill prescriptions if they perceive that they will have to pay the full monthly (shockingly high in many cases). J&J says that if list price disclosures are required for drugs, then hospitals, health insurers and pharmacy benefit managers should play by similar rules.” The drug manufacturers’ comments were submitted in response to proposed CMS rules. CMS has also required, beginning January 1, publication of hospital charges.
READINGS AND REFERENCES
MACPAC on Medicaid Hospital Inpatient Payment Systems: “This compendium documents how each state Medicaid program pays for inpatient hospital services under fee for service, including how each state sets its payment rates and the various adjustments and supplemental payments that states make. The compendium includes a summary tab with information on key policies across all states. In addition, there are state specific tabs that present a more detailed picture of each state’s Medicaid fee-for-service inpatient hospital payment policy.” Six hundred plus pages, state-by-state analysis, pivot tables, commentary on managed Medicaid, 300 plus acronyms, here.
Medicare Current Beneficiary Survey (MCBS): The MCBS 2015 Chart Book [here and slides, here] is now updated to include two new sections with information on the use and cost of health care services reported by survey beneficiaries. This release will supplement the information in Version 1 of the MCBS 2015 Chart Book which included information on beneficiaries’ satisfaction with care, usual source of care, functional status, and health and well-being. The MCBS is a continuous, multipurpose survey of a nationally representative sample of aged and disabled Medicare beneficiaries sponsored by CMS to collect information from beneficiaries that is not available in administrative data.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
Publication dates are the regularly scheduled days the House or the Senate is in session.
Remaining January publication dates: 4, 8, 9, 10, 11, 14, 15, 16, 17, 18, 28, 29, 30, 31
February publication dates: 1, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 25, 26, 27, 28
March publication dates: 1, 4, 5, 6, 7, 8, 11, 12, 13, 14, 15, 25, 26, 27, 28, 29
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.