DCMedical News: January 16, 2018
DCMedical News
Washington, D.C.
Tuesday, January 16, 2018
THE BIG STORY TODAY IN HEALTH CARE
Lots of attention to prices, what are they and why? What, if anything, can be done? Can we combine charges? What should we pay for—a service, a CMS-initiated “quality” metric, a “bundle”? Head-scratching, but no outrage, yet.
DOCTORS
CBO Studies Physician Prices: the Congressional Budget Office (CBO) has published a paper entitled “An Analysis of Private-Sector Prices for Physicians’ Services,” found here. The paper is unusual in that it has “not been subject to CBO’s regular review and editing processes,” is “being circulated to stimulate discussion and critical comment as developmental work for analysis for the Congress,” and is the first instance of a CBO publication on this specific subject.
The 43-page report compared payment to physicians in Medicare fee-for-service (FFS), Medicare Advantage (MA) and commercial health programs. It studied prices on 890 million services provided to 39 million patients covered by the insurers who are collectively the members of the “Health Care Cost Institute” (Aetna, Humana, United). The average commercial prices for the services selected were higher than Medicare FFS, much greater for specialty than for “routine” services. “Nationwide, average commercial prices ranged from 11% more than Medicare FFS for an office visit of an existing patient to more than double the price that Medicare FFS would pay for a brain magnetic resonance image, or MRI.” The study noted that, by contrast, insurers pay much lower prices under MA plans, compared to the prices they pay in their commercial lines. The MA prices ranged from 8% less than Medicare FFS to 8% more than Medicare FFS, for all 20 services studied. The median MA price was almost exactly the same as the Medicare FFS price. Moreover, MA prices were similar in and out-of-network, notwithstanding that the same commercial insurers who run the MA plans pay much higher prices for services which are out-of-network.
Other CBO-ers are busy: an exegesis of the process of “Estimating the Costs of Proposals Affecting Health Insurance Coverage,” January 10, here; and a projection of “CBO’s Estimates of Federal Subsidies for Health Insurance for People Under Age 65: 2017 to 2027,” also January 10, here.
HOSPITALS and HEALTH FACILITIES
Bundled Payments for Care Improvement-Advanced (BPCI-Advanced): New entry on the “bundled payment” saga, 29 inpatient and three outpatient “episodes” to begin. CMS says the list may be revised annually beginning January 1, 2020. This “episode of payment” bundle starts with an inpatient admission, the “anchor stay” at a hospital, or the beginning of an outpatient procedure, the “anchor procedure,” and ends 90 days later. Seven “quality” measures are involved in the BPCI-Advanced, two of them (hospital readmission and “advanced care plan”) are required for all 32 episodes, the other five applied prn. If you are following the story of physician payment bonuses through the “Quality Payment Program,” BPCI-Advanced qualifies as an “Advanced APM,” one of the two basic MACRA tracks for quality bonuses (the other, MIPS, now abandoned by MedPAC, see DCMN tomorrow). Participation begins this October 1, the first “performance period” going through the end of 2023. Application takes place (see graphic concerning explanation of the process here) March 12th, with a second application in January of 2020. CMS background is found here. The Times’ Robert Pear sees a “flip” in the new CMS adopting the old CMS bundling philosophy; read him here. JAMA has a piece on the “rise and fall” of the mandatory cardiac bundled payments, abstract found here. Talk about timing!
340B: The House Energy and Commerce Committee wants you to know that the profit (subsidy to hospitals from high payment for discounted drugs) may be gone, but not forgotten, and has published an 80-page collection of information, found here, in preparation for hearings, sometime.
Spread of High Medical Technology Nationwide Continues: CMS notes that the list of hospitals meeting CMS’s minimum facility standards for performing carotid artery stenting for high risk patients now totals 1,381 hospitals, with a separate list of 168 hospitals approved for ventricular assist devices (the latter credentialed by either DNV or TJC).
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
Medicare for all, Medicare for some more, Medicaid for all, and more: The Century Foundation sponsored a fest of “2020-ers,” Obama-era admins in exile and next-admin hopefuls, January 11 at the DC Kaiser HQ. The Prospect Magazine contains many of the excellent presentations, including sociologist Paul Starr on Medicare, academics Michael Sparer (Columbia) on Medicaid, Sherry Glied (NYU-Wagner) and many others. Read ‘em here.
CMS has gone after the non-disabled adult population on Medicaid, approving for Kentucky (here) an 1115 waiver application, in preparation for approving as many as ten more (see here), to require work or community service by those receiving Medicaid benefits. Behind the waiver: legal talent deciding that arbeit macht frei, or, if not free, at least healthy. The Medicaid statute does not have “promoting work” as one of its purposes, unlike the statutes authorizing food stamps (now SNAP) and other welfare programs. Therefore, implementing the Medicaid statute’s regulations and directives—even those, such as §1115, which exist to circumvent statutory requirements—called for a theory that work will promote health. (The Center for Budget and Policy Priorities is having a conference call on the Kentucky waiver this afternoon at 1:00 p.m., see schedule below.)
CMS has decided that, beginning January 1, it doesn’t want hospitals focused on controlling pain, but, rather, on communicating about pain (see HCAHPS new direction here. See also note below a CMS conference call on this subject, the “Hospital Open Door Forum,” today at 2:00 p.m.).
EVENTS & MEETINGS
Your January & February Calendar:
January 16: 1:00 p.m. CBPP and Georgetown on the Kentucky Medicaid Waiver, contact: MBell@CBPP.org
January 16: 2:00 p.m. CMS Hospital Open Door Forum, “Communication about Pain in HCAHPS Survey”
January 17: 9:30 a.m. Reinventing Rural Health, BiPartisan Policy Center, 1225 Eye Street, Washington, D.C.
January 17: 4:00 p.m. Regulatory Relief Webcast, AHA CEO Pollack and CMS Administrator Verma, contact: (800) 424-4301
January 23: 7:00 p.m. Senator Sanders with “Medicare for All Town Hall Meeting” on digital media outlets
January 25: 8:30 a.m. MACPAC, 1800 M. Street, Suite 650, Washington, D.C., and continuing to Friday, January 26
January 29: 8:30 a.m. COGME, at https://hrsa.connectsolutions.com/cogme-council/, also January 30
February 1: 9:00 a.m. Health Affairs, kick-off for cost control series, sponsored by National Pharmaceutical Council (!)
OTHER PUBLICATIONS
On prices: Austin Frakt and Michael Chernew, in JAMA, on-line January 4, 2018.
Having a hard time keeping up with which federal programs are expiring? A CBO publication with 164 pages of them (found here) will help.
DCMN: DC Medical News publishes every day that either the House or the Senate of the U.S. Congress is in session. Publication dates for the remainder of January: 17, 18, 19, 22, 23, 24, 25, 26, 29, 30, 31
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Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com