DCMedical News: Tuesday, September 17, 2019
DCMedical News-DCMN
Washington, D.C.
Tuesday, September 17, 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
Congress Returns Today
Both Houses of Congress are in session today, with nine legislative days remaining (calendar here) before the beginning of the federal government’s Fiscal Year 2020. (Examples of challenges to be overcome in nine days: spending levels and purposes in appropriations bills; continued authorization for multiple health programs; PPACA repair, including deferral of Disproportionate Hospital Share reductions). In appropriations measures, CQ has assembled a 17-page list (here) of funding controversies which remain in the spending bills (Labor-HHS-Education Departments shown on the 10th-12th pages of the unpaginated document).
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
Health Check-Ups? Worthless, Possibly Risky, Says British Study
That health check-up (is it ‘early screening for disease,’ or ‘marketing and case finding?’) is under skeptical scrutiny in the National Health. A summary in British Medical Journal (here) reports “NHS health checks are unlikely to be cost effective, can expose patients to unnecessary interventions, and risk overdiagnosis . . . The review, carried out by two academic GPs from the University of Oxford, looked at existing evidence on general health checks, including a recent Cochrane review, which it said showed that such checks had no significant effect on mortality or cardiovascular outcomes. In England the NHS Health Checks scheme currently offers checks to everyone aged 40 to 74. They are intended to spot the early signs of major conditions that cause early death, including stroke, kidney disease, heart disease, and type 2 diabetes.”
BMJ also presents a report (here) indicating that “GPs will be asked to avoid referring some patients to secondary care as part of a strict programme of service rationing . . . The North West London Collaboration of Clinical Commissioning Groups has also proposed cutting the number of outpatient appointments, restricting consultant to consultant referrals, and ‘repatriating’ elective operations from specialist centres outside the area to local hospitals.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
“Code Creep” Surges as Volume Declines in Massachusetts Hospitals
A report to the Health Policy Commission (here) indicates that price increases secondary to upcoding has compensated for revenue loss due to declining volume in Massachusetts hospitals. The result: higher commercial health insurance spending on inpatient hospitalization, growing almost 11% from 2013 to 2018, while volume decreased almost 13%. The cause for this spending increase: higher prices, in theory due to increases in patient acuity (metrics for how ill patients are, how many comorbidities, etc.). The HPC study contends that patients were not sicker; instead, a “risk score” used to help calculate payments increased more than 11% in those years, the “revenue equivalent of an additional 413,000 patients with diabetes or 888,000 individuals with cerebral palsy.” Moreover, an increased number of inpatient hospitalizations have taken place in larger, more expensive health systems: “The share of volume in the top five systems increased 18 percentage points from 2010 to 2017 . . . The share of volume in independent community hospitals declined 16 percentage points.”
HPC Also Studies Out-of-Network “Surprise” Billing Metrics
In a paper (here), the Massachusetts group summarizes examples of payments for typical out-of-network bills from hospital-based physicians. The staff compared these measures: 80th percentile of charges, median charges, 125% of median allowed amount, median allowed amount, 125% of the Medicare rate and the Medicare rate. Also, variation of charges within the state appears to be as least as dramatic as variation (in other studies) between states. For an emergency department visit of high severity (CPT 99285) the 80th percentile of charges ranges from $392 in the Pioneer Valley and Franklin area to $1,252 in New Bedford.
How common are out-of-network bills for insured patients? Mello and colleagues report (here) that “Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals.” For “ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8%” and “the percentage of inpatient admissions with an out-of-network bill increased from 26.3%to 42.0%.”
Mississippi Hospitals May opt Out of Statewide Trauma Network
Mississippi Today (here) reports that “Mississippi was the first state to mandate participation in a statewide trauma care system — a network of regional hospitals each designated to give a specific level of care, from basic stabilization all the way up to complex surgery — to triage high-need emergency patients across the state.” But hospitals wishing to avoid the high cost (and possibly un-or under-insured) severe trauma patient may pay to do so. “Although the state of Mississippi says that Jackson-based Baptist Medical Center and St. Dominic Hospital can provide care at a Level 2, each pays $1.5 million annually in what the state calls a non-participation fee for opting out of accepting Level 2 trauma patients. Both hospitals choose to operate as Level 4 facilities instead. Together, the hospitals paid the state more than $26 million since 2008 to avoid treating certain trauma patients as Level 2 facilities, according to state health department records Mississippi Today obtained.”
Nursing Homes Primed for Repeat of Recent Hospital History
October 1 marks the inauguration of a new Medicare reimbursement scheme (the Patient Driven Payment Model, CMS summary, here; “Technical” consultant report from Acumen, here) for nursing homes. Bloomberg reports that the new value-based payment system is meant to curb unnecessary or excessive treatment by rewarding efficiency, and that the “Patient Driven Payment Model” may be “especially challenging for small nursing homes that lack budgets for sophisticated billing systems.”
MEDICARE, MEDICAID, COMMERCIAL HEALTH INSURANCE
CMS Risk Adjustment: Hidden Profit for Medicare Advantage Plans or a Complete Waste of Money?
Dr. Samuel Young, a 3-M physician leader and blogger, reports on Medicare “risk adjustment,” a source of continued conflict between the Centers for Medicare and Medicaid Services (attempting to avoid “gaming” of risk to artificially increase payments) and Medicare Advantage Plans. Dr. Young describes “the model that the Centers for Medicare and Medicaid Services (CMS) uses to predict future Medicare Advantage health expenditures—the CMS-HCC model. The most recent evaluation of the 2018 version reveals that the model fails to account for up to 90 percent of the factors associated with healthcare expenditures.” Read more here.
READINGS AND REFERENCES
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.
Committees and Members at https://www.senate.gov/committees
House and Senate 2019 Calendar of Regularly Scheduled Sessions, here.
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
September publication dates: 18, 19, 20, 23, 24, 25, 26, 27
October publication dates: 15, 16, 17, 18, 21, 22, 23, 24, 28, 29, 30, 31
November publication dates: 12, 13, 14, 15, 18, 19, 20, 21
December 3, 4, 5, 6, 9, 10, 11, 12
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com.