State of the Union
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
The President delivers the State of the Union address tonight at 9:00 p.m. eastern. The Hill reports that the President will criticize the creation of panels to study the solvency of Social Security and Medicare. “In a nod to the ObamaCare fights, the White House said the bills would create death panels.”
“The dispute comes in the context of the ongoing debt ceiling debate. Republicans have publicly said they want to make spending cuts, but there's a major divide on what they actually want to cut. Medicare and Social Security are off the table, according to Speaker Kevin McCarthy (R-Calif.), but members say the programs will need reforms to be sustainable in the long term. So proposals like raising the eligibility age or means testing applicants could have some value, depending on which members you ask.”
The Hill continues, “In his speech on Tuesday, we expect the president to emphasize how he will push to protect Medicare, Medicaid, Social Security and ObamaCare. According to a White House fact sheet, he will also call on Congress to extend a price cap on insulin to all Americans, rather than just those with Medicare. The Inflation Reduction Act included a $35-per-month limit on insulin that took effect in January. Democrats initially wanted that policy to extend to private insurance too, but the effort was scaled back when Republicans successfully challenged its inclusion in the bill.”
“Biden is also going to tout Medicare's new ability to negotiate prices of certain drugs, as well as bipartisan legislation making hearing aids available over the counter.”
DOCTORS, NURSES AND OTHER HEALTH CARE PROFESSIONALS
Dangerous Business
Research in JAMA Network (here) found that excess physician deaths took place during the pandemic, but at a rate lower than that of the general population.
“From March 2020 through December 2021, US physicians experienced 622 more deaths than expected. There were no excess deaths among physicians after April 2021, coinciding with the widespread availability of COVID-19 vaccines. Across age groups, physicians had substantially lower excess mortality than the general population; however, active physicians had lower excess mortality than nonactive physicians despite their higher risk of contracting SARS-CoV-2 infection.”
“The findings suggest that personal protective equipment use, vaccine requirements, infection prevention protocols, adequate staffing, and other workplace-based protective measures were effective in preventing excess mortality.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Joint Commission Retreats From Standards Which Are “Above and Beyond”
The Joint Commission (TJC), which accredits more than 90% of American hospitals which choose to be accredited, has announced (here) a major retreat from standards which it believes exceed those of the federal government.
A news release from TJC says “The Joint Commission is eliminating a total of 168 standards (14%) and revising 14 other standards across its accreditation programs to streamline requirements and make them as efficient and impactful on patient safety, quality and equity as possible. The first tranche of standards deletions and revisions went into effect on Jan. 1. They include six deleted and one revised standard for the Laboratory Accreditation Program.”
“The standards reduction is the result of The Joint Commission’s comprehensive review that was announced in September 2022. The Joint Commission reviewed all its “above-and-beyond” requirements – those that go beyond regulatory requirements of the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) and are not on crosswalks to the CoPs.”
“CMS approved the recommended discontinued standards after confirming they do not diminish any CMS regulatory requirements. Importantly, a second tranche of standards is under consideration for elimination or revision, and a second announcement of burden reduction is anticipated in approximately six months.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Medicare Advantage Plans Denied 6 Percent of Prior Authorization Requests in 2021
The Kaiser Family Foundation (KFF, here) reports that “Medicare Advantage plans denied 2 million prior authorization requests in 2021, about 6 percent of the 35 million requests submitted that year.”
“The practice has been criticized by physician groups who argue it restricts and delays access to needed services. Eleven percent of the denials were appealed, and of those appeals, 82 percent resulted in fully or partially overturning the decision . . . In either case, medical care ordered by physicians or other practitioners ultimately deemed necessary by the insurers was potentially delayed by the prior authorization process . . . About 99 percent of Medicare Advantage beneficiaries are in plans that require prior authorization for some services, like chemotherapy or skilled nursing facility stays.”
CQ notes that “The analysis is in line with other studies on the issue, including a report from the Health and Human Services Office of Inspector General finding 5 percent of all requests were denied in 2018.”
Claims Denial Rarely Due to Medical Necessity, Most Are Unexplained, Not Appealed
KFF had previously reported (here) that “More than 200 million Americans are covered by private health insurance. But data from state and federal regulators shows that insurers reject about 1 in 7 claims for treatment.”
KFF wrote “CMS requires insurers to report the reasons for claims denials at the plan level. Of denials with a reason other than being out-of-network, about 16% were denied because the claim was for an excluded service, 10% due to lack of preauthorization or referral, and only about 2% based on medical necessity.”
“Among 2% of claims identified as medical necessity denials, 1 in 5 were for behavioral health services. Most plan-reported denials (72%) were classified as ‘all other reasons’, without a specific reason . . . Consumers rarely appeal denied claims and when they do, insurers usually uphold their original decision. In 2020, HealthCare.gov consumers appealed just over one-tenth of 1% of denied in-network claims, and insurers upheld most (63%) of denials on appeal.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
February 8, 9, 27, 28
March 1, 7, 8, 9, 22, 23, 24, 27, 28, 29, 30
April 17, 18, 19, 20, 25, 26, 27, 28
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org