State of the Union, Continued
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
The Hill reported (here) that in his State of the Union address President “Biden calls for insulin cost cap for all Americans. The Inflation Reduction Act capped the costs of insulin at $35, but only for people on Medicare. ‘Let’s finish the job this time. Let’s cap the cost of insulin at $35 a month for every American who needs it,’ Biden said.”
“He also vowed to defend the law from Republicans who want to repeal it. ‘Make no mistake, if you try to do anything to raise the cost of prescription drugs, I will veto it.’”
On Medicaid expansion, House Energy and Commerce Committee Chair Cathy Rodgers said “President Biden’s call for Congress to federalize Medicaid and end this important program as we know it would be another step closer to socialized medicine. Rather than radically expanding federal control, states must have the flexibility to serve patients in the most need as Medicaid was designed to do.”
The President spoke of the dramatic decline and end of the COVID-19 pandemic. The New York Times, however, noted that “On average, about 450 people in the United States are dying each day of Covid-19 . . .That number is way down from the roughly 3,200 Americans who were dying each day in early 2021, when the Omicron variant was ripping through the country. But the current daily average of Covid-19 deaths is higher than it was in December 2022, when roughly 250 Americans were losing their lives each day to the virus.”
DOCTORS, NURSES AND OTHER HEALTH CARE PROFESSIONALS
Federal judge rules against HHS — again — over surprise-billing arbitration rule
The Texas Medical Association and allies have prevailed in a suit against HHS over the arbitration process between out-of-network providers and payers established under the No Surprises Act. The “No Surprises Act” sought to protect patients from unexpected medical bills. It limits how much they can be charged for emergency and nonemergency services from out-of-network providers, and established an arbitration process for when payers and providers disagreed about those rates.
Judge Jeremy Kernodle’s Memorandum and Opinion (here) ruled that the revised arbitration process "continues to place a thumb on the scale" in favor of insurers and "that the challenged portions of the final rule are unlawful and must be set aside…"
Said Judge Kernodle, “When drafting the interim rule, the Departments had publicly expressed concern that arbitrators would select higher payment amounts favored by providers, resulting in higher healthcare costs. The interim rule therefore imposed a ‘rebuttable presumption’ that the offer closest to the QPA [Qualifying Payment Amount, the median in-network amount] should be chosen. This, the Departments explained, would ‘have a downward impact on health care costs’ by lowering payment amounts to providers.”
Corporate Investors in Primary Care: Medicine Capitated, Bundled, Value Based and Diminished
In The England Journal of Medicine, an opinion (here) on corporate investors in primary care holds that “These deals reflect a broader trend in the United States toward corporate investment in primary care, driven by an increasing focus
on “total-cost value-based care” — a model in which health care providers are paid to manage the total cost of care for their patients . . . Though potentially beneficial for certain well-insured patients, the trend of corporate investment in primary care could threaten equitable access to care, raise health care costs, and reduce physicians’ clinical autonomy.”
Meanwhile, the Boston Globe (here) reports on “Why You Can’t Get In To See Your Primary Care Doctor.” The authors write, “Across Massachusetts, people have been struggling to make appointments with primary care physicians, with doctors saying demand is higher than ever at a time when an increasing number of providers are leaving the field.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
New Rules May Be Coming for Hospital and Health System Consolidation
The Justice Department withdrew three antitrust policy statements pertaining to healthcare issued between 1993 and 2011. The announcement (here) noted that the withdrawn policy statements, jointly issued by the DOJ and Federal Trade Commission, are well known and often referenced for their guidance on information sharing.
The non-binding but advisory statements are the Department of Justice and FTC Antitrust Enforcement Policy Statements in the Health Care Area (Sept. 15, 1993); Statements of Antitrust Enforcement Policy in Health Care (Aug. 1, 1996); and the Statement of Antitrust Enforcement Policy Regarding Accountable Care Organizations Participating in the Medicare Shared Savings Program (Oct. 20, 2011).
“Over the past three decades since this guidance was first released, the healthcare landscape has changed significantly. As a result, the statements are overly permissive on certain subjects, such as information sharing, and no longer serve their intended purposes of providing encompassing guidance to the public on relevant healthcare competition issues in today’s environment.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
CMS Quality Measures Called Out as Complex, Overlapping and Duplicative. And Redundant.
A perspective in The England Journal of Medicine (here) finds that “CMS operates more than 20 quality programs focused on individual clinicians, certain health care settings such as hospitals or skilled nursing facilities, health insurers, and value-based entities such as accountable care organizations.”
“Each of these programs has its own set of quality measures; entities report on and are held accountable for their performance on various measures. Although some of these measures are consistent across our programs, many are not. Insurers often use the same quality measures as CMS (such as the Medicare Part C and D star ratings or plan-level measures for Medicaid managed care organizations) to adjust clinician reimbursement as part of value-based arrangements — although some insurers use different or modified measures, which has also contributed to measure proliferation.”
Dually Eligible Beneficiaries
The Data book on beneficiaries dually eligible for Medicare and Medicaid, produced by MedPAC and MACPAC, is here.
Do Medicaid Patients in Independent Physician Practices Receive High Quality Primary Care?
The Commonwealth Fund examined this question (here). They found that “About three-quarters of nonelderly adult Medicaid patients get their primary care from independent office-based practices, rather than hospital outpatient departments or health centers. But many independent physicians don’t accept Medicaid, in part because of its low payment rates. Medicaid-covered care is concentrated in a small share of independent, typically under resourced practices . . . From 2014 to 2019, about one-third of sampled office-based primary care physicians accounted for 90 percent of Medicaid office visits. Patients are as likely to receive guideline-recommended care at Medicaid-dominated practices as they are at practices with more non-Medicaid patients.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
February 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