|Lawmakers Want CMS’ Prior Authorization Proposal to Go Further
By Andrew Cass | June 21, 2023
More than 230 U.S. representatives and 61 senators are asking HHS and CMS leaders to bolster a proposed rule aimed at streamlining the prior authorization process, Politico reported June 21.
A letter sent to the leaders was spearheaded by Washington Rep. Suzan DelBene, who was one of the sponsors of a bill in 2022 that attempted to reform the Medicare Advantage prior authorization process. The bill passed the House but died in the Senate over concerns about its projected $16 billion cost, according to the report.
Ms. DelBene told Politico that the rule CMS proposed in December makes “huge strides forward for seniors,” but “we think it needs to go further.”
The lawmakers are asking CMS to add provisions to the proposed rule to align more with the legislation that passed the House last year, according to the report.
The provisions include:
Real-time prior authorization for routine matters.A 24-hour deadline for Medicare Advantage plans to answer prior authorization requests for urgently needed care. More detailed transparency metrics. CMS set a December 2025 deadline to finalize the rule, but the agency said it will publish it sooner if possible, according to the report.
To read more, go to Becker’s Payer Issues.
AMA Opposes Non-Compete Agreements for Hospital-Employed Physicians
By Victoria Bailey | June 19, 2023
The American Medical Association’s (AMA) House of Delegates has voted to oppose non-compete agreements for physicians employed by hospitals or staffing companies.
Non-compete agreements prohibit employees from working for a competitive employer or starting a competing business during their current employment or for a specific duration after their job has ended.
There has been some debate on non-compete agreements among AMA’s members. Physician practice owners may favor using reasonable non-competes, while employed physicians may support banning the agreements.
The House of Delegates opposed non-compete contracts for certain physicians, including those employed by for-profit or nonprofit hospitals, hospital systems, or staffing company employers.
“Allowing physicians to work for multiple hospitals can enhance the availability of specialist coverage in a community, improving patient access to care and reducing health care disparities,” Ilse Levin, DO, MPH&TM, DM, AMA Board of Trustees member, said in the press release.
According to AMA, non-compete agreements have impacted up to 45 percent of primary care physicians, especially as more physicians are working directly for hospitals or practices that are partially owned by a hospital over private practices.
Additionally, non-compete agreements can limit career opportunities and advancements for recently graduated trainees entering the workforce. These contracts can also limit trainees’ ability to provide care in underserved areas, AMA said.
While the Accreditation Council for Graduate Medical Education (ACGME) prohibits restrictive contracts as a contingency for residents or fellows in GME training programs, some non-ACGME fellowship programs require trainees to sign non-compete agreements.
Some states, including California, North Dakota, and Oklahoma, have already banned non-compete contracts. Other states have banned the agreements specifically for physicians, including New Hampshire, Delaware, Massachusetts, and Rhode Island.
In January 2023, the Federal Trade Commission proposed a ban on non-compete agreements, estimating that it would increase wages by almost $300 billion per year and expand career opportunities for 30 million people. However, the ban would not cover nonprofit hospitals, which account for 57 percent of all hospitals.
To read more, go to Revcycle Intelligence.
ASA Supports New FDA Guidance on Drug Shortages
June 16, 2023
Last week, the American Society of Anesthesiologists (ASA) submitted formal comments in support of the Food and Drug Administration’s (FDA) new drug shortage guidance. The new guidance, which targets notification for drug production interruption and discontinuation, assists drug manufacturers in “providing FDA timely, informative notifications about changes in the production of certain finished drugs and biological products as well as certain active pharmaceutical ingredients (API) that may, in turn, help the Agency in its efforts to prevent or mitigate shortages.” This FDA guidance is an important step in ensuring adequate and consistent patient access to drugs that improve outcomes and care.
The guidance highlights the importance of notifications to the FDA to maintain awareness of availability of drugs that are needed to care for patients. Enhanced communication between manufacturers and the FDA ensures that all stakeholders receive relevant information as quickly as possible.
Based on prior recommendations drafted at a 2018 ASA-convened summit on drug shortages, the 2023 comment letter also offered the FDA additional recommendations, including:
Incentivize compounding pharmacies and manufacturers to increase production and reduce costs. Coordinate with partners in other countries to streamline international regulations and incentivize increased production. Support and explore methods to assess the risk of foreign sourced active pharmaceutical ingredients (API). Encourage manufacturers to develop contingency or redundancy plans for drug production, specifically when there are fewer than three manufacturers producing a drug or when the drug is identified as “critical.” Convene discussions between manufacturers, hospitals, medical stakeholders, and others that assess current regulations on repackaging medications, including single-dose vials.Participate in and encourage cross-collaboration on drug concentration standardization actions, including by standardizing medical concentration, containers, and sizes to stabilize pharmaceutical supply and reduce the probability of patient harm. Ensure that the health care provider community can manage drug shortages via up-to-date technology and early communication about potential drug shortages. This week, the FDA submitted its annual Report on Drug Shortages to Congress, which highlights the COVID-19 pandemic’s continuing strain on the pharmaceutical supply chain and summarizes actions taken by the FDA to mitigate or prevent shortages. Anesthesiologists began reporting rising shortages of equipment and medical devices, such as certain epidural kits, syringes, and IV/A-line catheters, in July 2022.
To read more, go to ASA’s website.
Delaware Opts Out of CRNA Supervision Requirement
By Riz Hatton | June 16, 2023
Delaware has opted out of federal regulations requiring physician supervision of certified registered nurse anesthetists.
Governors of 24 states and Guam have also exercised this exemption for a full or partial opt-out, according to a June 15 news release from American Association of Nurse Anesthesiology.
“Through this action Delaware recognizes that CRNAs are qualified to make decisions regarding all aspects of anesthesia care based on their education, licensure and certification,” Marshall Colbert, CRNA, president of the Delaware Association of Nurse Anesthetists, said in the release.
To read more, go to Becker’s ASC.
CMS Publishes 2021 Quality Payment Program Experience Report and Infographic
June 15, 2023
This week, the Centers for Medicare and Medicaid Services (CMS) released the 2021 Quality Payment Program (QPP) Experience Report, along with an associated infographic. QPP participants can access these materials for data on general performance and participation in the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) for the 2021 performance year.
Among CMS’ highlights:
93.85% of MIPS eligible clinicians engaged (submitted data for one or more performance categories) in QPP.86.12% of MIPS eligible clinicians received a positive payment adjustment in 2021 despite the minimum score for a positive payment adjustment increasing from 45 to 60 points.96.69% of MIPS eligible clinicians avoided a negative payment adjustment.Access the 2021 Experience Report Public Use File for more detailed information.
To read more, go to ASA’s website.
Medicaid Disenrollments Top 1 Million
By Rylee Wilson | June 13, 2024
More than 1 million people have been disenrolled from Medicaid as part of the redeterminations process, according to KFF.
As of June 12, at least 1,027,000 people have lost Medicaid coverage, according to data reported by state agencies analyzed by KFF. Not all states have publicly reported data on Medicaid disenrollments.
Around half of those disenrolled live in Florida, Arizona and Arkansas. Florida has disenrolled nearly 250,000 individuals as of June 12.
Some states began terminating coverage for ineligible Medicaid recipients in April after continuous coverage requirements in place during the COVID-19 public health emergency ended.
Many individuals who have lost Medicaid coverage were disenrolled because they did not return required paperwork or other procedural reasons, rather than being determined ineligible for the program.
In seven states — Kansas, Indiana, Connecticut, West Virginia, Florida, Arkansas and New Hampshire — more than 80 percent of those disenrolled from Medicaid were due to procedural reasons, according to KFF’s analysis.
In a June 12 letter to state governors, HHS Secretary Xavier Becerra urged states to do more to prevent procedural disenrollments.
“I am deeply concerned with the number of people unnecessarily losing coverage, especially those who appear to have lost coverage for avoidable reasons that State Medicaid offices have the power to prevent or mitigate,” Mr. Becerra wrote.
The agency implemented new flexibility for states aimed at curbing the number of people unnecessarily disenrolled from the program.
To read more, go to Becker’s Payer Issues.
15 Statistics on the Anesthesia Industry
Riz Hatton | June 13, 2023
Here are 15 statistics on anesthesiologist compensation, debt and more.
This information comes from Medscape’s “Anesthesiologist Lifestyle, Happiness & Burnout Report 2023,” “Anesthesiologist Compensation Report 2023” and “Physician Wealth & Debt Report 2023.
Burnout and mental health
Fifty-eight percent of anesthesiologists said they are happy outside of work.Thirty-five percent of anesthesiologists said they are burned out.Six percent of anesthesiologists said they are depressed.Eighty-seven percent of anesthesiologists said they have not sought professional help for burnout.Fifty-seven percent of anesthesiologists said they would take less pay for a better work-life balance.
The average annual compensation for anesthesiologists is $448,000.The average incentive bonus for the specialty is $68,000.Male anesthesiologists earn about 10 percent more than women in the field.Fifty-eight percent of anesthesiologists said they feel fairly paid.
Wealth and debt
Thirteen percent of anesthesiologists are worth more than $5 million. Nineteen percent of anesthesiologists are worth less than $500,000.Nineteen percent of anesthesiologists are still paying off student loans.Miscellaneous
Seventy-five percent of anesthesiologists said they would choose medicine again.Eighty-seven percent of anesthesiologists said they would choose the specialty again.Anesthesiologists spend nine hours a week on paperwork and administration.
To read more, go to Beckers ASC.
High-cost Claims on the Rise, Especially Among Youth
By Jeff Lagasse | June 8, 2023
Nearly eight in 10 employers consider drug prices, high-cost claims and hospital prices a significant threat to the affordability of employer-provided health coverage for employees and their families, and high-cost claims are rising, especially among younger plan members, finds a new survey from the National Alliance of Healthcare Purchaser Coalitions (NAHPC).
Almost half describe $100,000 as the lower limit for a high-cost claim. Some use $50,000 as a threshold to identify potential high-cost claims early.
More than half the participating employers have experienced high-cost claims of $2 to $4 million in the last few years, and they’re seeing a rise in high-cost claims for younger plan members, with more than $1 million claims disproportionately weighted toward that demographic. The top conditions for these claims include cancer, prenatal/neonatal care, and treatment for COVID-19.
WHAT’S THE IMPACT
Employers have historically been more reliant on third-party administrators (TPAs) and pharmacy benefit managers (PBMs) to manage high-cost claims. As costs have escalated, employers want to learn how best to hold service providers accountable for better management, the survey found.
About 34% of employers set out-of-pocket maximums at $3,000 or below, while 42% have maximums of $3,000–$5,000. Almost 20% of employers have out-of-pocket maximums of $6,000 or more.
Most employer strategies include a focus on managing complex cases (65%) and addressing the cost of specialty drugs (64%). Other strategies employers are deploying include using a specialty carve-out; implementing a patient assistance program (PAP); case management (via TPAs); reassessing stop-loss insurance; and accessing alternative, more affordable sources of medications, such as biosimilars.
The highest priority areas for employers over the next couple years include offering precision medicine for cancer treatment (45%); implementing centers of excellence (39%); negotiating and auditing hospital prices (34%); auditing intermediaries (30%); and mitigating costs and coverage of rare diseases (30%).
To read more, go to Healthcare Finance News.
Fortune 500’s Top 5 Payers
Andrew Cass | June 5, 2023
The 69th Fortune 500 was released June 5. Five payers were included in the top 25 on the annual list of the largest corporations in the U.S. ranked by revenue for the 2022 fiscal year.
Here are the top 5 ranked payers with their revenue and percentage change to annual revenue:
1. UnitedHealth Group (No. 5 on Fortune 500)
2022 revenue: $324.16 billion
Change to revenue: 12.7 percent
2. CVS Health (No. 6 on Fortune 500)
2022 revenue: $322.46 billion
Change to revenue: 10.4 percent
3. Cigna (No. 15 on Fortune 500)
2022 revenue: $180.51 billion
Change to revenue: 3.7 percent
4. Elevance Health (No. 22 on Fortune 500)
2022 revenue: $156.59 billion
Change to revenue: 13 percent
5. Centene (No. 25 on Fortune 500)
2022 revenue: $144.54 billion
Change to revenue: 14.7 percent
To read more go to Becker’s Payer Issues.
How CMS’ Reimbursement Policies Have Helped, Hurt ASCs in 2023
By Riz Hatton | June 1, 2023
CMS’ policies have the power to turn the tide of the surgery center industry. Here is how those policies have both helped and hurt ASCs in 2023.
CMS updated ASC payment rates to 3.8 percent in its 2023 “Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule.”In December, CMS submitted a 134-page proposal designed to improve prior authorizations for Medicare and Medicaid patients through automating the process and improving workflows. The proposal requires certain payers to address the administrative hassles of prior authorization by requiring the implementation of an automated process, meeting shorter time frames for decision-making and improving transparency.In its 2023 final rule, CMS implemented a policy that provides complexity adjustments for certain ASC procedures. According to VMG Health’s 2023 mergers and acquisitions report, these adjustments are applied to “combinations of primary procedures and add-on codes deemed eligible under the hospital [outpatient prospective payment system].” Previously, add-on codes did not receive more reimbursement when bundled with primary codes. This policy allows Medicare to provide adjustments to the payment rate to account for the costs of specific services.
The conversion factor used to calculate physician reimbursement declined by $1.55 to $33.06 in 2023, representing a 4.48 percent decrease.In November, CMS released the Medicare payment and policy change final rule. The rule kept a 2 percent Medicare reimbursement cut to physicians in 2023, and 2024 may bring at least another 1.25 percent cut.In its 2023 final rule, CMS considered 64 recommendations for new procedures to be added to the ASC-covered procedures list, but only four procedures that are typically performed in an outpatient setting were chosen.
To read more, go to Becker’s ASC.