DCMedical News: January 18, 2018
DCMedical News
Washington, D.C.
Thursday, January 18, 2018
THE BIG STORY TODAY IN HEALTH CARE
Delay in consensus concerning the budget (Continuing Resolution) continues, more issues raised by parties on all sides.
DOCTORS
At MedPAC’s January 11 and 12 meeting a report was given (slides found here) assessing payment adequacy for ambulatory surgery centers. MedPAC reports that, in 2016, Medicare paid $4.3 billion to 5,532 ASCs for service to 3.4 million beneficiaries, with Medicare payment per beneficiary INCREASING 3.5% FROM 2015 TO 2016. More quality reports were called for, as well as a requirement for ASCs to submit cost data.
American health system unique? Not so much. Wednesday’s Financial Times (found here) describes the failure of Germany’s Social Democrats (SPD) to form a coalition with Christian Democrats (CD). The CD has objected to “consolidation” of public and private health insurance plans. “Christian Democrat experts argue that money from private patients - - the industry took €37.2bn in premiums in 2016 - - helps fund innovation, while competition between the private and statutory sectors produces high-quality care for all. Meanwhile the private insurance industry warns of the hit to doctors’ practices, which derive 25 per cent of their revenues from the 10 per cent of people with private insurance.” The FT notes that “Doctors can charge private patients on average 2.5 times more for the same service, so the privately insured tend to get an appointment more quickly - - and are offered a broader range of services. Under the SPD plan, doctors would have received the same fee for the same service. All new patients would have had to join the same universal scheme.”
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
Medicaid: cause or cure (or both, or neither) for opioid epidemic. Senator Ron Johnson of Wisconsin has petitioned HHS and CMS to examine Medicaid’s “perverse incentives” in fueling opioid use. His letter (found here) says “While there is clearly no single cause to the epidemic, evidence has emerged that Medicaid is playing a perverse and unintended role in helping to fuel and fund the opioid epidemic. I write to provide the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) with the results of an examination into the perverse incentives created by Medicaid that contribute to the opioid crisis. I respectfully request information and material about what the Department is doing to prevent improper use of the Medicaid program to obtain opioids.”
The report to which Johnson refers (164 pages, found here) is summarized on pgs. 6-8, and says “Medicaid has contributed to the nation’s opioid epidemic by establishing a series of incentives that make it enormously profitable to abuse and sell dangerous drugs. Growing evidence indicates that the Medicaid expansion, by providing prescription opioids to a wider pool of people, may be worsening the epidemic. At least 1,072 people have been convicted or charged nationwide since 2010 for improperly using Medicaid to obtain prescription opioids, some of which were then resold on the nation’s streets. The number of criminal defendants increased 18 percent in the four years after Medicaid expanded, 2014-2017, compared to the four years prior to Medicaid expansion. The criminal activities range from beneficiaries simply selling opioids they obtained through the Medicaid program to more attenuated health care fraud involving Medicaid reimbursement.”
Advocates for continued expansion of Medicaid have contended the opposite, that treatment options for addiction would be severely curtailed in the absence of Medicaid coverage. In addition, proposals have been made that, for the first time since Medicaid’s passage in 1965, inpatient mental health services would be covered by Medicaid, without limitation on the size of the facility.
In the House, members of the Ways and Means Oversight Subcommittee were considering proposals to add treatment options and to introduce prescribing restrictions to curb opioid abuse under the Medicare program. Specifics included standardization of prior authorization processes, expanding access to opioid alternatives, including methadone as an outpatient treatment option. Regulations proposed November 28th (found here) for Part D and MA programs would limit opioid-using patients to a single pharmacy and also finalize a case management program.
HOSPITALS
More on MedPAC: meetings on January 11 and 12 (agenda here, members here, 2018 schedule here) included a report on the Hospital Readmissions Reduction Program (slides here). Reports of readmission rates began in 2009, the HRRP began in 2010 and payment rates were first reduced in 2013 (for hospitals with high readmission rates 2010-2012).
This report is required by the 21st Century Cures Act. Results: a 17% decrease in admissions per capita, 2010-2016, some shifted to outpatient, many one-day stays reduced, resulting increase in patient complexity (real or coding), with steady climb in observation and ED use. Contrary to a peer reviewed study in California, MedPAC staff found “little relationship between changes in readmission rates and mortality rates for heart failure patients.” Bottom line: MedPAC reports a $2 billion savings because of the HRRP for the Part A (hospital) Trust Fund.
PHARMA
MedPAC also received a report on the prescription drug program, Part D of Medicare, slides found here. Of the 59 million Medicare beneficiaries in 2017, 42.5 million enrolled in Part D plans, with program spending of $80 billion, and $13 billion in premiums excluding subsidies and other cost-sharing programs. The “doughnut” and the “hole” are shown on the fourth slide, with cost thresholds. Enrollment in MA plans was up, low income subsidies (LIS) were down, although growth of LIS enrollees was up. Rebates grew from less than 10% to 22% during the past ten years, especially in “price protection” schemes. In pricing of drugs, “growth in brand prices [single-source brand-name drugs] more than offsets effects of generic use,” and “Nearly all of the growth in spending for high-cost enrollees is due to higher prices.”
EVENTS & MEETINGS
Your January & February Calendar:
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
Do hospital global budgets matter for “health system reform”? This week’s JAMA (published on-line January 16, free, here, looked at the Maryland experiment, now two years in. Findings: “We found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland’s program.” And, “We did not find consistent evidence that Maryland’s hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years.”
Correction: the link in this excerpt from yesterday’s DCMN led to the wrong article: “In an unrelated January 3rd letter to CMS, found here, MedPAC commented on other issues with the MA program.” Here is the link to the MedPAC letter.
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: 19, 22, 23, 24, 25, 26, 29, 30, 31
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Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com