DCMedical News: Monday, June 10, 2019
DCMedical News-DCMN
Washington, D.C.
Monday, June 10, 2019
DCMedical News is published every day both the House and the Senate are in session. Subscription information below.
THE BIG STORY IN HEALTH CARE
The American Medical Association’s new leader Dr. Patrice Harris is inaugurated at the group’s annual meeting in Chicago, will focus on mental health and healthcare equity.
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Limits on Pension Pay for NHS Doctors Creates Peril for UK Single Payer
The Financial Times reports (here) that “The prime minister has been urged by doctors’ leaders to intervene over pension changes that risk creating ‘a crippling workforce crisis’ in the NHS and could even jeopardise the government’s ability to deploy troops. The British Medical Association called on Theresa May to use her final days in office to address rules under which high earners, such as hospital consultants and GPs, can see their annual allowance — a limit on the amount that can be contributed to a pension each year, while still receiving tax relief — tapered to as low as £10,000. An investigation by the Financial Times earlier this year found that consultants were refusing to take on extra work that could have helped to slim lengthening queues for treatment, for fear of busting the new allowances. The issue has also been blamed for a rising number of family doctors taking early retirement.”
More on Single Payer for the U.S.
Drs. Steffie Woolhandler and David Himmelstein make the case (here) for a single payer plan in the U.S., from the May 31 JAMA. Useful footnote references and reminders such as these: “The current, fragmented payment system entails complexity that adds no value. Physicians and hospitals must navigate contracting and credentialing with multiple plans and contend with numerous payment rates and restrictions, preauthorization requirements, quality metrics, and formularies. Narrow clinician and hospital networks and the constant flux of enrollment/disenrollment as patients change jobs or their employers switch plans disrupt long-standing patient physician relationships. Many insurers devote resources to recruiting profitable enrollees and encouraging unprofitable enrollees to disenroll. This complexity drains resources from patient care . . . The complex payment system also increases hospital costs and prices. Single-payer nations, such as Canada and Scotland, pay hospitals global budgets, analogous to the way US cities fund fire departments. That payment strategy obviates the need to attribute costs to individual patients and insurers and minimizes incentives for upcoding, gaming quality metrics, bolstering profitable ‘service lines,’ and other financially driven exertions.”
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
DSH Bill:
House Democrats are still looking for the $50 billion “pay-for” which would be necessitated by the proposal of Rep. Eliot Engel (H.R. 3022) for complete elimination of the Disproportionate Hospital Share (DSH) reductions mandated by the Patient Protection and Affordable Care Act. (Assuming that Medicaid expansion and exchange programs would “eliminate” the uninsured, and/or provide payment for services to them in safety net hospitals, PPACA required phasing out of the DSH program beginning in FY 2014. In the face of evidence that 30 million remain uninsured in America, Congress has postponed implementation of the program, now schedule to begin in FY2020, this October 1.)
For background, see MACPAC, here, https://www.macpac.gov/subtopic/disproportionate-share-hospital-payments/.
In 2014, according to the Medicaid and CHIP Payment and Access Commission, Congress mandated a “Report to Congress on Medicaid Disproportionate Share Hospital Payments” in February 2016 and an annual update each March. Congressional concerns included these: “The relationship of state DSH allotments to (1) changes in the number of uninsured individuals, (2) amounts and sources of hospitals’ uncompensated care costs, and (3) the number of hospitals with high levels of uncompensated care that also provide access to essential community services for low-income, uninsured, and vulnerable populations.” The 2016 report is here, the 2019 update here, also a list of DSH and other supplemental payments by State (here) and a profile of the type of hospitals receiving DSH funds (here).
The bottom line from MEDPAC this March: “The analyses in this chapter underscore MACPAC’s prior findings that DSH allotments have little meaningful relationship to measures of uncompensated care at the state level. Much of the variation in state DSH allotments reflects their basis on historic patterns of spending. We also find that CMS’s methodology for implementing DSH allotment reductions would preserve most of this historical variation.” Republican House and Senate members favor a two-year extension of the DSH payment reduction moratorium, reportedly to examine these issues, and/or, having done so, find a “permanent” solution.
Of interest, the profile of State supplemental Medicaid payments (here) shows that, overall, nearly 50% (on average) of State Medicaid payments come from these “supplemental” sources (DSH, §1115 Waivers, etc.).
Step Therapy to be Allowed in Medicare Drug Programs and Medicare Advantage
Medicare Advantage plans will have a further advantage beginning January 1, the ability to compel their enrollees to participate in “step therapy” when those enrollees require outpatient pharmaceuticals. The final regulations (here) also involve minimal changes to the “protected classes” of drugs. “This final rule amends the Medicare Advantage (MA) program (Part C) regulations and Prescription Drug Benefit program (Part D) regulations to support health and drug plans' negotiation for lower drug prices and reduce out-of-pocket costs for Part C and D enrollees. These amendments will improve the regulatory framework to facilitate development of Part C and Part D products that better meet the individual beneficiary's healthcare needs and reduce out-of-pocket spending for enrollees at the pharmacy and other sites of care.”
Organized medicine has been opposed (here), however, and even academic physicians lukewarm (here). The AMA and a host of physician specialty societies attempted to persuade CMS that “Step therapy protocols that require patients to try and fail certain treatments before allowing access to other, potentially more appropriate treatments can both harm patients and undercut the physician-patient decision-making process.” Dr. Michael Fischer of Brigham and Women’s Hospital reported that “The most concerning and preventable instance of how step therapy can interrupt a preferred regimen is change in insurance status resulting from change in job or employer-provided coverage. Changes in formulary, even for patients with stable insurance, can also adversely affect treatment. In these circumstances, patients for whom one regimen has truly failed may unexpectedly be subjected to new step therapy requirements, forcing them to switch from their current medication to whatever agent is the ‘first step’ in their new plan. Paradoxically, medication decisions and costs are often managed in a different ‘silo’ from other decisions, outcomes, and costs for which a physician is responsible, as when drug costs are ‘carved out’ by a Medicare Part D drug benefit that is decoupled from the rest of a given patient’s coverage.”
READINGS AND REFERENCES
This Would Appear to be Pretty Fundamental—Correctly Identifying the Patient
A host of mainstream insurance, information system, hospital and professional societies are trying once again to eliminate a legislative obstacle to patient identification. In a letter to Congressional leaders, the group (here) writes “For nearly two decades, innovation and industry progress has been stifled due to a narrow interpretation of the language included in Labor-HHS bills since FY1999, prohibiting the U.S. Department of Health and Human Services (HHS) from adopting or implementing a unique patient identifier. More than that, without the ability for clinicians to correctly connect a patient with their medical record, lives have been lost and medical errors have needlessly occurred. These are situations that could have been entirely avoidable had patients been able to have been accurately identified and matched with their records. This problem is so dire that one of the nation’s leading patient safety organization, the ECRI Institute, named patient identification among the top ten threats to patient safety.”
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
June publication dates: 11, 12, 13, 25, 26, 27, 28
July publication dates: 9, 10, 11, 12, 15, 16, 17, 18, 23, 24, 25, 26
August publications dates: None
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.