| Anesthesiology Digest: News from February 2023. |
| High-deductible Health Plans are Moving Health Outcomes in the Wrong Direction By Jakob Emerson | February 22, 2023 As the number of Americans enrolled in high-deductible health plans continues to grow, recent studies conducted by researchers at some of the nation’s top hospitals and medical schools have linked HDHPs with worse health outcomes, less spending on preventive care, and higher utilization rates of emergency rooms. High-deductible health plans are defined as plans that meet the minimum deductible amount required for health savings account eligibility — $1,400 for an individual and $2,800 for a family in 2021. In 2021, more than 56 percent of private-sector Americans were enrolled in a HDHP — the highest state is Maine (76 percent) while the lowest is Hawaii (11.6 percent). Conclusions of five HDHP studies recently reported by Becker’s: 1. A study published Jan. 20 in JAMA Network Open found that diabetic patients who were forced to enroll in a HDHP by their employer face a higher risk of acute diabetes complications compared to those enrolled in traditional health plans. HDHPs increased the risk of needing to visit the emergency room or hospital for severe hyperglycemia by 25 percent, and each year of enrollment increased the risk by 5 percent. 2. A study presented Nov. 29 by Boston Medical Center researchers to the Radiological Society of North America found that over 21 percent of women surveyed said they would not seek an additional screening after abnormal findings on a mammogram if they knew they had to pay a deductible. 3. A study published Oct. 5 in the American Journal of Managed Care found that individuals with HDHPs were 6.6 percent less likely to receive treatment for substance use disorders than those with traditional health plans. 4. An observational study presented in June by Harvard Medical School researchers at the American Society of Clinical Oncology’s annual meeting linked HDHPs with a 4.6 month delay in the detection of metastatic cancer compared to individuals enrolled in a low-deductible plan. 5. A study published May 9 in the American Journal of Managed Care found that when HDHPs are present, employees making less than $75,000 annually spend more on emergency care and have higher acute care utilization rates, and they have lower rates of primary care spending compared with high-salary employees. To read more, go to Becker’s Payer Issues. |
CMS Instructs IDR Entities to Hold Payment Determinations By Jacqueline LaPointe | February 16, 2023 CMS recently instructed certified independent dispute resolution (IDR) entities to hold all payment determinations until the Departments of Health and Human Services, Labor, and the Treasury issue further guidance. The federal agency announced the hold in a Feb. 10 email to subscribers. The email also said that certified IDR entities must recall any payment determinations issued after Feb. 6, 2023. The US District Court for the Eastern District of Texas issued a judgment and order on Feb. 6, vacating certain parts of federal regulations implementing the IDR process under the No Surprises Act (NSA). This is the second court ruling regarding the implementation of the IDR process. “The Departments are currently reviewing the court’s decision and evaluating current IDR processes, guidance, templates, and systems for updates that will be necessary to comply with the court’s order,” CMS said in the email. “The Departments will provide specific directions to certified IDR entities for resuming the issuance of payment determinations that are consistent with the court’s judgment and order. Certified IDR entities should continue working through other parts of the IDR process, including eligibility determinations, as they wait for additional direction from the Departments.” Judge Jeremy D. Kernodle of the US District Court for the Eastern District of Texas ruled earlier this month that certain parts of the revised IDR process following an August 2022 rule from the Departments were inconsistent with the NSA. In a previous case from nearly a year ago, Judge Kernodle held that an interim final rule from the Departments also contradicted the NSA by imposing “rebuttable presumption” that the offer closest to the qualifying payment (QPA) amount should be chosen. The Departments then replaced the interim final rule with rulemaking in August 2022. However, the Texas Medical Association, which filed the original lawsuit, also sought to vacate the new final rule. They argued that, just like the interim final rule, the new rule put more emphasis on the QPA relative to other factors, such as patient acuity, clinician characteristics, and market share. Judge Kerndole agreed with the Texas Medical Association and other plaintiffs. The payment determination pause issued by CMS earlier this month will delay the IDR process, according to Max Czernin, partner at Squire Patton Boggs, writing in The National Law Review. It is also likely to lead to further backlogs as new claim disputes are submitted, Czernin wrote. A report from the Departments describes a significantly higher volume of claims than the Departments initially estimated. Payers and providers submitted over 90,000 disputes from April 15 through September 30, 2022, the report stated. The Departments had estimated in the 2021 interim final rule that 17,333 claims would be submitted as part of the federal IDR process each year. Payers and providers can submit a dispute to the IDR process if both parties fail to arrive at an agreed-upon payment amount during a 30-day open negotiation payment for items and services covered by NSA, which include surprise bills for emergency services, non-emergency items and services furnished by out-of-network providers at in-network facilities, and services provided by out-of-network air ambulance providers. The IDR process is a “baseball-style” arbitration process in which both parties submit payment amounts and explanations to a certified IDR entity, which then selects one of the proposed amounts based on certain factors, including the QPA. The IDR process launched on April 15, 2022. To read more, go to Revcycle Intelligence. |
ASA Urges Expanded Batching of No Surprises Act Claims February 14, 2023 The American Society of Anesthesiologists (ASA) is urging the Center for Consumer Information and Insurance Oversight (CCIIO) to ease existing rules and guidance regarding the batching of anesthesia claims in the No Surprises Act’s (NSA) Independent Dispute Resolution (IDR) process. On February 14, in a formal communication to CCIIO, ASA sought a policy change that will permit anesthesiologists to group or batch all of their anesthesia claims from the same insurance issuer when submitting claims to an IDR entity. Currently, under the direction of CCIIO, IDR entities may only adjudicate single claim disputes and batched disputes that include only claims with the same CPT code. This restrictive policy represents a significant operational burden on anesthesiologists and their practices. Further, with the January 1, 2023, 600% increase from $50 to $350 of the non-refundable IDR administrative fee, practices will face a substantial financial burden until the current batching policy can be revised. Note: ASA has filed a joint amicus brief in support of a Texas Medical Association lawsuit challenging the fee increase. The correspondence with CCIIO follows a face-to-face meeting and conference calls on the batching issue with the agency in January. To read more, go to ASA’s website. |
With Oak Street Health Deal, CVS Pushes Healthcare Ambitions as Investment in Value-based care Heats Up By Heather Landi | February 9, 2023 At the end of 2021, CVS Health CEO Karen Lynch laid out a strategic vision for the drugstore retail chain to expand beyond pharmacy services. During the company’s investor day more than a year ago, Lynch and company executives detailed plans to enhance the company’s capabilities in health services and primary care. With its proposed $10.6 billion acquisition of Medicare-focused primary care player Oak Street Health, which was announced Wednesday morning, CVS is moving forward aggressively on that strategy. This latest deal comes just five months after CVS said it would spend about $8 billion in cash to buy Signify Health, a home health and technology company. Back in August during the company’s second-quarter earnings call, Lynch said CVS, which operates nearly 10,000 drugstore locations across the country, is looking to enhance its health services in provider enablement, home health and primary care. CVS’ intent to buy Signify Health checks the first two boxes while Oak Street Health checks the third one. “Oak Street Health has a proven senior-focused primary care model that is scalable at a national level. We see a significant opportunity to expand in the next few years and provide superior care to many more patients,” Lynch said during CVS’ fourth-quarter earnings call Wednesday. To read more, go to Fierce Healthcare. |
Only 25% of Hospitals Are Complying with the Price Transparency Rule By Victoria Bailey | February 8, 2023 Less than a quarter of hospitals are complying with the hospital price transparency rule over two years after the regulation went into effect, according to a report from PatientRightsAdvocate.org. The Fourth Semi-Annual Hospital Price Transparency Report reflects publicly available data from 2,000 hospitals in the US. Researchers assessed the hospitals’ websites from December 10, 2022, to January 26, 2023. The price transparency regulation went into effect on January 1, 2021, and requires hospitals to post prices online in a user-friendly format. For complete compliance, facilities must publish a machine-readable file that includes the standard charges and discounted cash prices for all items and services for all health plans and a ‘standard charges’ display with actual prices or a price estimator tool for the 300 most common shoppable services. The latest review from PatientRightsAdvocate.org revealed that only 489, or 24.5 percent, of the 2,000 hospitals fully complied with the price transparency rule requirements. This indicates that over 1,500 hospitals were noncompliant. Nearly 6 percent of hospitals (116) were noncompliant and did not post any standard charge files. Around half of the hospitals (51.3 percent) posted negotiated prices that were associated with payers and health plans, but 49.8 percent of those still were not in compliance because most of their pricing data was missing or incomplete. Three-quarters of the hospitals (1,506) did not publish a complete machine-readable file of standard charges, 975 (48.8 percent) did not publish all payer-specific negotiated charges, and 923 (46.2 percent) did not post a sufficient amount of negotiated rates. In addition, 327 hospitals (16.4 percent) did not post any discounted cash prices and 116 (5.8 percent) did not publish any usable standard charges pricing file. For the shoppable services requirement, 411 hospitals (20.5 percent) presented charges in a consumer-friendly format. However, 362 of those hospitals were noncompliant because their standard charges files were incomplete. Similarly, 1,716 hospitals (85.8 percent) published a price estimator tool, but 73.4 percent of them were noncompliant due to incomplete standard charges files. Twenty-one hospitals showed backsliding, meaning they were noncompliant in the most recent report but were compliant in PatientRightsAdvocate.org’s August 2022 report. Meanwhile, 116 of the hospitals that were noncompliant in the August report were deemed compliant in the new report. To read more, go to Revcycle Intelligence. |
Federal Judge Rules Against HHS ─ Again ─ Over Surprise-Billing Arbitration Rule By Jakob Emerson | February 7, 2023 A federal judge in Texas has handed another win to the Texas Medical Association and medical providers nationwide against HHS over a challenge to the arbitration process between out-of-network providers and payers that was established under the No Surprises Act. On Feb. 6, U.S. District Judge Jeremy Kernodle 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…” The lawsuit was originally filed in September alongside UT Health Tyler Regional Hospital and a physician. The AHA and the AMA, along with 30 additional national and state medical groups, filed amicus briefs in support of the lawsuit. Insurance trade group AHIP filed in support of HHS. Insurers had argued that there was “no basis” to providers’ claims and that there were even “early signs of a beneficial trend, where the [No Surprises Act] has furthered good faith network negotiations over reasonable rates.” The 2020 No Surprises Act protects patients from unexpected medical bills and limits how much they can be charged for emergency and nonemergency services from out-of-network providers. It also established an arbitration process for when payers and providers disagreed about those rates. Under an interim final rule unveiled in July 2021, CMS directed the arbitrator in the independent billing dispute resolution process to assume that the qualifying payment amount (QPA), or the median in-network rate set by payers, is the appropriate out-of-network rate. The TMA filed a lawsuit Oct. 28, 2021, challenging the rule, alleging that CMS, under President Joe Biden’s leadership, failed to follow clear direction from Congress about implementing the dispute resolution process. At the time, the association said the process was a “short-sighted approach” that would drive down reimbursement rates and encourage payers to narrow their networks. A federal judge agreed and ruled against the administration in February 2022 — a decision that was appealed by HHS in April. CMS released a revised final rule Aug. 19, which the TMA claimed still gave too much of an advantage to payers during arbitration. “Similar to before, the new final rules unfairly advantage insurers by requiring arbitrators to give outsized weight or consideration to an opaque, insurer-calculated amount — called the qualifying payment amount — when choosing between an insurer’s offer and a physician’s offer in a payment dispute,” TMA President Gary Floyd, MD, said. “This is unfair to physicians, providers, and the patients we care for, so we had to seek fairness.” In the Feb. 6 decision, Mr. Kernodle vacated all of the revised regulations challenged by the TMA, including HHS’ rule that arbiters must primarily consider the QPA. The TMA filed a third lawsuit against HHS in November 2022, alleging portions of the rule “artificially deflate the QPA.” A fourth lawsuit from the association was filed in January 2023 that challenges a 600 percent hike in administrative fees when seeking dispute resolutions. To read more, go to Becker’s Payer Issues. |
ASA Files Joint Amicus Brief in Support of Lawsuit Challenging Qualifying Payment Amount February 3, 2023 On January 31, the American Society of Anesthesiologists, American College of Emergency Physicians, and American College of Radiology®, filed a joint amicus brief in support of a pending Texas Medical Association (TMA) lawsuit that challenges the No Surprises Act Qualifying Payment Amount (QPA). The suit, the third of four TMA suits, argues that key aspects of the federal government’s Surprise Billing interim final rule (IFR) that apply to the QPA are badly flawed and impose serious financial pressures on physician practices. The amicus brief also notes that the IFR hinders physicians and facilities from engaging in fair contracting negotiations with insurers, which could result in more physicians and facilities being forced out-of-network. Read the full press release. |
CMS Seeks to Make Quality Measures More ‘Universal’ in Rollout of New Program By Robert King | February 2, 2023 Top Medicare and Medicaid officials want to create a “universal foundation” of quality measures aligned across all programs in a bid to ease reporting burdens and confusion. Officials with the Centers for Medicare and Medicaid Services called for aligning quality measures across more than 20 agency programs in a letter in the New England Journal of Medicine Thursday. CMS’ Universal Foundation aims to focus provider attention on the quality measures which affect the largest segments of a patient population and advance health equity. “Our intention is that the Universal Foundation will eventually include selected measures for assessing quality along a person’s care journey—from infancy to adulthood—and for important care events, such as pregnancy and end-of-life care,” according to the NEJM letter. The letter lays out the initial preliminary measures as part of the foundation, which will eventually be used across all CMS programs to the extent they are applicable. To read more, go to Fierce Healthcare. |
CMS Proposes Small Bump in MA Payments, Sweeping Risk Adjustment Changes By Rylee Wilson | February 2, 2023 CMS is expecting a small revenue bump of 1.03 percent on average for Medicare Advantage and Part D plans in 2024 as part of a slate of potential risk adjustment and star ratings changes that has some industry leaders concerned. In an advance notice published Feb. 1, the agency proposed a rate increase of 2.09 percent for MA and Part D plans next year, largely driven by increases in fee-for-service costs, and a MA risk score trend of 3.3 percent. The agency also signaled a 3.12 percent decline in payments based on proposed changes to the risk adjustment model, and a 1.24 percent decline in payments based on changes to the star ratings system — 2023-star ratings will impact quality bonus payments in 2024. In addition, CMS proposed shifting MA’s diagnosis coding from ICD-9 to ICD-10 in 2024 — the latter has been used since 2015 and by more physicians. CMS said these changes will “keep the model up to date and improve payment accuracy.” The proposed rule builds on a risk adjustment rule finalized by CMS Jan. 30 that could leave Medicare Advantage plans on the hook for up to $4.7 billion in repayments to the federal government. See the full advance notice here. To read more, go to Becker’s Payer Issues. |
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