DCMedical News: Thursday, January 31, 2019
DCMedical News-DCMN
Washington, D.C.
Thursday, January 31, 2019
DCMedical News is published every day either the House or the Senate is in regular session.
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THE BIG STORY IN HEALTH CARE:
HHS Fermenting Against Stark, AKS: Modern Healthcare reports that Deputy Secretary Eric Hargan told a Brookings gathering Wednesday that HHS is ramping up its work to overhaul the Stark Law and anti-kickback statute and its regulations. “Right now we're currently in the fermenting stage in the development of the rule.” The process began with a “Request for Information” in June (here) which drew 3,500 pages of suggestions.
But is HHS Fermenting the Right Brew? Kanter and Pauly check in on the issues raised with Stark and AKS by HHS’ Hargan (here) in this week’s New England Journal of Medicine (“Coordination of Care or Conflict of Interest? Exempting ACOs from the Stark Law”). These authors note “Despite this promising possibility [of vertical integration generally], studies have shown scant evidence of cost reductions. Studies of integrated delivery systems in the 1990s revealed negligible reductions in cost and little quality improvement. Studies of more recent mergers between hospitals and physician practices have shown that vertical integration has resulted in price increases and has had mixed effects on care quality. And evaluations of Medicare ACOs have shown minimal cost savings for Medicare.” Why? They write, “when ACOs are paid under fee-for-service systems, as most are, physicians have an incentive to refer patients to hospitals and for other services within the system — the classic conflict-of-interest problem that the Stark law was trying to address. Moving from a fee-for-service system to bundling or a capitation-based system, in which providers are paid fixed amounts, would not necessarily improve matters, however, since there is evidence that such systems could lead to stinting on care and reduced quality.” More on this piece tomorrow.
HOSPITALS AND OTHER HEALTH CARE FACILITIES
New Rules for Veterans’ Access to Private Sector Medical Care: The VA announced Wednesday (here) “proposed access standards for community care and urgent care provisions that will take effect in June and guide when Veterans can seek care to meet their needs under the MISSION Act – be it with VA or with community providers.”
The access standards are “based on average drive time and appointment wait times. For primary care, mental health, and non-institutional extended care services, VA is proposing a 30-minute average drive time standard. For specialty care, VA is proposing a 60-minute average drive time standard. VA is proposing appointment wait-time standards of 20 days for primary care, mental health care, and non-institutional extended care services, and 28 days for specialty care from the date of request with certain exceptions. Eligible Veterans who cannot access care within those standards would be able to choose between eligible community providers and care at a VA medical facility.”
For urgent care, “Eligible Veterans will have access to urgent (walk-in) care that gives them the choice to receive certain services when and where they need it. To access this new benefit, Veterans will select a provider in VA’s community care network and may be charged a copayment.”
In a separate statement (here), VA Secretary Wilkie denied that the new standards amounted to privatization of VA services. He said, “Since 2014, the number of annual appointments for VA care is up by 3.4 million, with over 58 million appointments in fiscal year 2018. Simply put, more Veterans are choosing to receive their health care at VA. Patients’ trust in VA care has skyrocketed – currently at 87.7 percent – and VA wait times are shorter than those in the private sector in primary care and two of three specialty care areas.”
Costly LVAD Outliers: A University of Michigan group reporting on Left Ventricular Assist Devices in JAMA Cardiology (here) found that “[P]rice-standardized and risk-standardized Medicare spending varied by 35% between the lowest and highest spending quartile centers, which was primarily driven by differences in outlier payments between hospitals. Patients treated in higher-spending hospitals had longer postimplant length of stay but similar clinical outcomes.” A commentary (here) notes the innovative nature of the study, but cautions that “there were clues that the highest-cost quartile centers had sicker patients.”
“Rehabbed to Death”: The title of a piece (here) in this week’s NEJM on financial incentives for post-discharge care in nursing homes. According to the authors, “[P]olicy could continue to move toward removing incentives for nursing homes to hospitalize long-stay residents covered by Medicaid. Currently, nursing homes have particular incentives to hospitalize residents who are eligible for both Medicare and Medicaid, because these patients can return to the nursing home on the higher-paying Medicare post-acute care benefit before transitioning back to long-term care with lower Medicaid day rates. Higher Medicaid day rates for long-term care might reduce the churn of long-stay residents between hospital and nursing home near the end of life.”
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
Bid Documents (“2020 Medicare Advantage and Part D Advance Notice Part II and Draft Call Letter”) Propose Non-Medical Condition Coverage and Other Flexibility for MA and Part D Plans: CMS proposed Wednesday (fact sheet here, 210-page letter here) still more flexibility for Medicare Advantage (MA) and Part D drug plans in tailoring non-medical benefits to meet the needs of individual patients. The proposal calls for: a 1.59% increase for the MA and Part D plans (compared to 3.4% for this year); waiving uniformity (as called for in the Bipartisan Budget Act of 2018) for patients who share a common condition to allow non-medical benefits, for example meals to homebound patients with dietary restrictions; targeting patients with chronic pain or substance abuse, in a bid to help curb the ongoing opioid epidemic; and a new risk adjustment model that would incorporate the number of conditions a patient has when determining risk scores. Comments on the proposal are due March 1.
Anthem CEO Discusses Care Coordination (and More) in Quarterly Earnings Call: In the call (transcript here) Wednesday, CEO Gail Boudreaux said “Anthem Whole Health Connection connects medical, pharmacy, dental, vision and disability clinical and claims data to improve member's overall health, well-being and cost of care. This clinically integrated model is producing tangible results. During 2018, 1.2 million specialty gaps in care were communicated and closed. Through Whole Health Connection, we have been able to lower emergency room visits and inpatient hospital stay by 8%, reduced the number of dental OPA prescriptions by 40% and identified more than 130,000 members with high-risk health conditions through routine eye exams.”
READINGS & REFERENCES
“HEALTH INSURANCE EXCHANGES, Claims Costs and Federal and State Policies Drove Issuer Participation, Premiums, and Plan Design”: A new Government Accountability Office report (here) discusses insurance company results on the exchanges created by the Patient Protection and Affordable Care Act, analyzing premium, plan designs and claims.
U.S. House of Representatives: Members at https://www.house.gov/representatives, Committees and Members at https://www.house.gov/committees
U. S. Senate: Members at https://www.senate.gov/general/contact_information/senators_cfm.cfm, Committees and Members at https://www.senate.gov/committees/membership_assignments.htm
House and Senate 2019 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
Publication dates are the regularly scheduled days the House or the Senate is in session.
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Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.