IPPS, Continued
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The proposed payment “rule” for the CMS Inpatient Prospective Payment System (here) will affect much more than operating and capital payments for acute care and long-term acute care hospitals for the federal fiscal year (2024) which begins October 1, 2023.
Wage Disparities, GME, Critical Access Hospitals
Says CMS, “In this FY 2024 proposed rule, we are proposing to continue policies to address wage index disparities impacting low wage index hospitals. We are also proposing to make changes relating to Medicare graduate medical education (GME) for teaching hospitals and new technology add-on payments. We are proposing to establish new requirements and revise existing requirements for eligible hospitals and CAHs participating in the Medicare Promoting Interoperability Program.”
Proposed Continuation of the Low Wage Index Hospital Policy
“To help mitigate growing wage index disparities between high wage and low wage hospitals . . . we adopted [for 2020] a policy to increase the wage index values for certain hospitals with low wage index values (the low wage index hospital policy) . . . We also indicated our intention that this policy would be effective for at least 4 years, beginning in FY 2020, in order to allow employee compensation increases implemented by these hospitals sufficient time to be reflected in the wage index calculation. As discussed in section III.G.4. of the preamble of this proposed rule, as we only have 1 year of relevant data at this time that we could use to evaluate any potential impacts of this policy, we believe it is necessary to wait until we have useable data from additional fiscal years before making any decision to modify or discontinue the policy. Therefore, for FY 2024, we are proposing to continue the low wage index hospital policy and the related budget neutrality adjustment.”
Value Based Purchasing, HCAHPS, Hospital Acquired Conditions, HRRP
Writes CMS, “In the Hospital VBP Program, we are proposing to add one new measure, substantively modify two existing measures, add technical changes to the administration of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey, and change the scoring policy to include a health equity scoring adjustment and modify the Total Performance Score (TPS) maximum to be 110, resulting in numeric score range of 0 to 110.”
“We are also providing estimated and newly established performance standards for the FY 2026 through FY 2029 program years for the Hospital VBP Program. In the HAC Reduction Program, we are proposing to establish a validation reconsideration process for data validation and to add an additional targeting criterion for validation. We are not proposing any changes to the Hospital Readmissions Reduction Program.”
DSH Payment Adjustment and Additional Payment for Uncompensated Care
“Under section 1886(r) of the Act, which was added by section 3133 of the Affordable Care Act, starting in FY 2014, Medicare disproportionate share hospitals (DSHs) receive 25 percent of the amount they previously would have received under the statutory formula for Medicare DSH payments in section 1886(d)(5)(F) of the Act. The remaining amount, equal to 75 percent of the amount that otherwise would have been paid as Medicare DSH payments, is paid as additional payments after the amount is reduced for changes in the percentage of individuals that are uninsured. Each Medicare DSH will receive an additional payment based on its share of the total amount of uncompensated care
for all Medicare DSHs for a given time period. In this proposed rule, we are proposing to update our estimates of the three factors used to determine uncompensated care payments for FY 2024.”
Indian Health Service and Tribal Hospitals, Puerto Rico
“Beginning with FY 2023, we established a supplemental payment for IHS and Tribal hospitals and hospitals located in Puerto Rico, to help prevent undue long-term financial disruption to these hospitals due to discontinuing use of the low-income insured days proxy in the uncompensated care payment methodology for these providers.”
Hospital Value-Based Purchasing (VBP) Program
In the “Hospital VBP Program . . . we are proposing to adopt modified versions of: (1) the Medicare Spending Per Beneficiary (MSPB) Hospital measure beginning with the FY 2028 program year; and (2) the Hospital-level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) measure beginning with the FY 2030 program year. We are also proposing to adopt the Severe Sepsis and Septic Shock: Management Bundle measure in the Safety Domain beginning with the FY 2026 program year.”
“Additionally, we are proposing to adopt a health equity scoring change for rewarding excellent care in underserved populations beginning with the FY 2026 program year.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
UK Health Personnel Management a Mess
The Financial Times reports (here) that “Staff shortages in education and health are worse than in any other area of the UK economy as public sector wages fall further behind those offered in the private sector, according to a survey of employers,” and that (here) “there are now an estimated 18,000 UK-trained doctors practising overseas. This is a 50 per cent increase since 2008. To put it another way, one in seven practising doctors who trained in Britain is now working elsewhere. This is almost three times the average rate among peer countries.”
MEDICARE, MEDICAID, AND COMMERCIAL HEALTH INSURANCE
Medicaid Disenrollment Begins, Early Results
InsideHealthPolicy (here) reports that in Arkansas “54,300 people were disenrolled from health coverage in April because they couldn’t be located, didn’t return their renewal form on time or did not answer a request for more information.” Also, in Idaho, which announced plans to complete redeterminations within eight months, “The Idaho Department of Health and Welfare’s latest data as of Monday (May 15) show the department has processed nearly 51,000 redeterminations so far and determined about 30,800 beneficiaries are ineligible.”
Claims Denials, Target of a State Effort
Connecticut’s Office of the Healthcare Advocate decries lazy and arbitrary insurer claims denials (here). “The Centers for Medicare and Medicaid Services (CMS) requires health insurance companies to report the reasons for claims denials. About 14% denied the claim because the service was not covered, 8% due to lack of pre-authorization or referral and about 2% due to medical necessity. Shockingly, the overwhelming majority of reported denials were classified as ‘all other reasons.’”
“But years into the ACA, the federal government is still not demanding full transparency. The data is not being collected, (‘all other reasons’ is a junk, lazy category that provides no useful information to consumers or healthcare providers) nor is the data being audited. Just one specific example: This information is critical in providing oversight to the issue of compliance with the Mental Health Parity and Addiction Equity Act and would reveal whether claims denial rates differ for behavioral versus other healthcare claims.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
May 17, 18
June 6, 7, 8, 11, 12, 13, 14, 20, 21, 22, 23
July 11, 12, 13, 14, 18, 19, 20, 25, 26, 27, 28
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org
© 2023 Fred Hyde & Associates, All rights reserved.
Editor: Jane Guillette; Systems and Distribution: Colby Miers, Los Angeles