DCMedical News: January 23, 2018
DCMedical News
Washington, D.C.
Tuesday, January 23, 2018
THE BIG STORY TODAY IN HEALTH CARE
Three days out, now three weeks forward with a Continuing Resolution to fund government activities to February 8.
The Senate approved a three week Continuing Resolution (CR) to fund the government. Included in the CR is a six-year reauthorization of the Children’s Health Insurance Program (CHIP), and deferral of three health-related taxes. The tax suspensions include “ . . a one-year suspension of the health insurance tax (to 2020), a two-year suspension of the medical device excise tax (to 2020), and a two-year suspension of the Cadillac tax on high-cost employer-sponsored health care plans (to 2022), all of which were creatures of the Patient Protection and Affordable Care Act (PPACA, ‘Obamacare,’ P.L. 111-148 and 111-152).”
The CBO estimate of the cost of the three tax suspensions (“on-budget” = $31 billion) appears on pg. 4 of the CBO estimate of the cost of the CR provisions, found here. Last week the House (230-197) passed its own CR. The Senate Monday passed a new CR (81-18 for cloture, ending debate) which includes the identical six-year funding extension of CHIP and suspensions of the medical device, Cadillac, and health insurance taxes. The measure subsequently passed the House Monday night, 266-150.
No action has been taken yet on reauthorization of funds for community health centers; on “extenders” in the Medicare program including rural assistance and therapy caps; on 340b payments to hospitals for safety net patients; or on any matters involving sequestration in the FY 2018 budget. No action has been taken either on Alexander-Murray (cost-sharing reduction payment reimbursement) or on Collins-Nelson (state reinsurance programs or high risk pools).
DOCTORS, NURSES, OTHER HEALTH PROFESSIONALS
Physician payment adjustments, continued.
At its January 11-12 meeting, MedPAC wrestled with physician payment adjustment, ultimately voting to recommend to Congress that the Merit-based Incentive Payment program (MIPS) be eliminated. MIPS was one of two alternatives under MACRA (the Medicare and CHIP Reauthorization Act of 2015) which physicians could pursue for payment increases (or under which they might suffer payment decreases). One program subsumed under MACRA’s MIPS was the Value Payment Modifier. In the “small world” category, CMS announced (in the Medicare Learning Network “Connects” publication January 18) the results of the 2018 Value Modifier (VM) and the adjustment factor that will be applied to clinicians receiving an upward payment adjustment in 2018. MLN reported that “over 20,000 clinicians will receive an increase of 6.6% to 19.9% on their Medicare physician fee schedule payments as a result of their high performance on quality and cost measures in 2016.” The announcement continued, “The Merit-based Incentive Payment System under the new Quality Payment Program is replacing the Value Modifier.” Of course, events have overtaken both the VM and MIPS.
MedPAC also discussed what some members and staff perceive as imbalances in payment for primary care and specialty services by physicians. Specifically, they discussed proposals to pay more for primary care services by cutting rates for other services. MedPAC first discussed the issue at its November meeting, transcript here.
Discussion focused on the ”imbalance” between “fee-schedule time estimates” and “actual hours worked,” with variance for some specialties (cardiology, orthopedics) much greater than for others (family medicine). One option discussed would increase rates 10 percent for psychiatric and ambulatory evaluation and management (E&M) services by all doctors, paid for by cutting rates by 4-5%. No vote is imminent. The MedPAC schedule calls for a March 2018 report on assessing payment adequacy for physician services and a June 2018 report on “Rebalancing fee schedule towards ambulatory E&M services.” Slides from the January 12 presentation can be found here.
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
Medicaid’s advisory body (and CHIP’s, as well), MACPAC, meets this coming Thursday and Friday. The agenda, found here, will include substance abuse disorders and institutional treatment. A MACPAC discussion paper on Medicaid and FQHCs is found here. A summary of the 2017 Medicaid and CHIP “Stats” book can be found here. A summary (January 16, 2018) of the status of CHIP funding for FY 2018 can be found here.
MACPAC also plans to vote as part of its final March report to Congress on recommendations to streamline Medicaid managed care authorities, specifically to allow states to use their Medicaid state plans rather than seeking waiver authority to compel Medicaid beneficiaries to enroll in managed care.
The group will also debate the role of residential facilities—including institutions for mental diseases (IMDs)—in the treatment of substance use disorders under Medicaid. The “IMD Exclusion” prohibits the use of federal Medicaid financing for care provided to most patients in mental health and substance use disorder residential treatment facilities larger than 16 beds.
The exclusion, present since the beginning of the Medicaid program, has an exception for inpatient psychiatric services provided to beneficiaries under age 21. The exclusion has long been a barrier to efforts to use Medicaid to provide nonhospital inpatient behavioral health services. The purpose of the exclusion was to make sure that the states, rather than the federal government, were responsible for funding inpatient psychiatric services.
In his remarks in October concerning the opioid epidemic, the President announced his plan to “unlock treatment for people in need.” He added, “As part of this emergency response, we will announce a new policy to overcome a restrictive 1970s-era rule that prevents states from providing care at certain treatment facilities with more than 16 beds for those suffering from drug addiction.”
The Government Accountability Office (GAO) published a report on IMDs (found here) in August. The number of inpatient mental health hospital beds for adults decreased from approximately 290,000 in 1990 to approximately 190,000 in 2008, according to the GAO report, a 35% decline.
Miscellany:
From the 1-22 “Healthsprocket,” via Gallup: % of Uninsured U.S. Adults
1. Ages 18-64: 12.2% in Q4 2017 2. Ages 18-25: 16.7% in Q4 2017 3. Ages 26-34: 20.1% in Q4 2017 4. Ages 35-64: 12.8% in Q4 2017 5. Ages 65+: 2.1% in Q4 2017
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: 9:15 a.m. MACPAC, to 3:45 p.m., 1800 M. Street, Suite 650, Washington, D.C., continuing to January 26
January 25: 9:00 a.m. through January 27, Families USA, Health Action 2018 conference, Hyatt Regency Capitol Hill
January 25: 2:00 p.m. Commonwealth Fund media call on Association and Short-Term Health Plans
January 29: 8:30 a.m. COGME, at https://hrsa.connectsolutions.com/cogme-council/, continuing January 30
February 1: 9:00 a.m. Health Affairs, kick-off for cost control series, sponsored by National Pharmaceutical Council
OTHER PUBLICATIONS
CMS: Publication of 2016 Medical Loss Ratio reports, found here
HFMA: Analysis of CMS’ Center for Medicare and Medicaid Innovation request for applications for Bundled Payment for Care Improvement (BPCI) payment model, found here
JAMA: Goldman, et. al., “Out-of-pocket Spending and Premium Contributions After Implementation of the Affordable Care Act,” JAMA Internal Medicine 1-22-2018, found here.
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: 24, 25, 26, 29, 30, 31
To our new readers: This is an independent newsletter, with no corporate, foundation, trade group or other funding. Those with paid subscriptions will receive a minimum of 100 issues per year, publishing at least every day that one or another House of Congress is in session.
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com