Anesthesiology Digest – September 20, 2021

September 30, 2021

Anesthesiology Digest: News from September 2021.

ASCs Livid Over CMS Plan to Curb Approved Procedures
By Michael Brady | September 20, 2021

Ambulatory surgery centers are fuming over potentially losing more than 250 procedures they can offer patients if the Centers for Medicare and Medicaid Services reinstates the inpatient-only list limiting them to hospitals, according to comments on CMS’s proposed outpatient pay rule for 2022.

Ambulatory surgery centers argue that CMS doesn’t have enough information to support such a significant policy change. The providers also claim the agency made a series of flawed assumptions about the real-world impact of restoring the inpatient-only list and limiting the procedures allowed under the ambulatory surgery center covered procedures list, known as the ASC-CPL, according to the Ambulatory Surgery Center Association.

“While ASCA was not expecting the 267 codes that were proposed—and later finalized—to be added to the ASC-CPL in 2021, we were even more surprised that one year later CMS is proposing to completely reverse course. We have serious concerns with the way this was handled and the discussion surrounding this issue included in the proposed rule,” ASCA wrote in a letter. “The same medical officers who allowed for the codes’ addition in 2021 are now claiming, without evidence, that these codes may not be safely performed in the ASC setting.”

CMS maintains that halting reimbursements to ambulatory surgery centers for hundreds of procedures would have little effect because ambulatory surgery centers had not yet started performing the newly added procedures. But that isn’t true, the ASCA wrote.

“This supposition ignores the reality that it takes time to add new procedures in a facility, and the data CMS would have at this point in the year is extremely limited. In addition, CMS’s addition of codes to the ASC-CPL often opens the door for other payors to reimburse for these procedures, and as such, many facilities may have started with other patient populations before taking on any sort of significant Medicare volume,” ASCA wrote.

To read more, go to Modern Healthcare.

ASA Provides Feedback to CMS on Issues Included in the 2022 OPPS Proposed Rule
September 20, 2021

ASA has submitted comments to the Centers for Medicare and Medicaid Services (CMS) on issues included in the Outpatient Prospective Payment and Ambulatory Surgical Systems proposed rule.

• ASA supports CMS’s decision to halt the elimination of the Inpatient Only (IPO) list. We offer a list of concerns CMS should take into account as it considers future action and urge the agency to work collaboratively with all stakeholders as it considers next steps.
• ASA offers feedback in response to the Request for Information on Rural Emergency Hospitals included in the proposed rulemaking specific note of the need for access to tertiary care, appropriate use of telehealth and other remote service capacities and the need to address maternal morbidity and mortality rates.
• ASA urges CMS to finalize its proposal to expand its policy of separate payment for certain non-opioid pain medications beyond the ACS environment and to include the hospital outpatient environment.

CMS will consider all comments and release a final rule later this year.
To read more, go to ASA’s website.

Over Half of States Have Rolled Back Public Health Powers in Pandemic
By Lauren Weber & Anna Maria Barry-Jester | September 15, 2021

Republican legislators in more than half of U.S. states, spurred on by voters angry about lockdowns and mask mandates, are taking away the powers state and local officials use to protect the public against infectious diseases.

A KHN review of hundreds of pieces of legislation found that, in all 50 states, legislators have proposed bills to curb such public health powers since the covid-19 pandemic began. While some governors vetoed bills that passed, at least 26 states pushed through laws that permanently weaken government authority to protect public health. In three additional states, an executive order, ballot initiative or state Supreme Court ruling limited long-held
public health powers. More bills are pending in a handful of states whose legislatures are still in session.

In Arkansas, legislators banned mask mandates except in private businesses or state-run health care settings, calling them “a burden on the public peace, health, and safety of the citizens of this state.” In Idaho, county commissioners, who typically have no public health expertise, can veto countywide public health orders. And in Kansas and Tennessee, school boards, rather than health officials, have the power to close schools.

President Joe Biden last Thursday announced sweeping vaccination mandates and other Covid measures, saying he was forced to act partly because of such legislation: “My plan also takes on elected officials in states that are undermining you and these lifesaving actions.”

All told:
• In at least 16 states, legislators have limited the power of public health officials to order mask mandates, or quarantines or isolation. In some cases, they gave
themselves or local elected politicians the authority to prevent the spread of infectious disease.
• At least 17 states passed laws banning Covid vaccine mandates or passports, or made it easier to get around vaccine requirements.
• At least nine states have new laws banning or limiting mask mandates. Executive orders or a court ruling limit mask requirements in five more.

To read more, go to Kaiser Health News.

ASA Submits Comments on CMS’ Proposed Rule for the CY2022 MPFS/QPP
September 13, 2021

In comments to the Centers for Medicare and Medicaid Services (CMS), ASA provides strong feedback to CMS on many issues of importance. These include concerns about the CY 2022 Medicare Conversion Factors, the valuation of specific anesthesia and pain medicine services, resource costs for services that use innovative technologies, separate coding and payment for chronic pain management, anesthesia for certain colorectal cancer screens, telehealth, and split billing of critical care services. We provide detailed feedback on Quality Payment Program proposals for 2022, including how the MIPS Value Pathways mechanism will be implemented. We encourage CMS to finalize the “Patient Safety and Support of Positive Experiences with Anesthesia MIPS Value Pathway (MVP)” and agree with their proposal to reduce the reporting burden for those reporting an MVP. ASA also supports CMS in increasing the Perioperative Surgical Home Improvement Activity to a “High-Weighted” activity. We disagree with CMS in their proposals to remove bonus opportunities in MIPS as well as their proposal to increase the reporting rate in future years.

We expect that CMS will issue a final rule and determination on these features of the MPFS and QPP later this year.

To read more, go to ASA’s website.

Biden to Toss Medicare Coverage for “Breakthrough” Technology
By Michael Brady | September 13, 2021

The Centers for Medicare & Medicaid Services wants to repeal a Trump-era rule allowing Medicare to cover medical devices designated as “breakthrough” technology by the Food and Drug Administration, according to a proposed rule on Monday.

Former President Donald Trump’s administration had said the original rule was necessary because the existing Medicare coverage determination process is too slow and could delay beneficiaries’ access to the latest medical technology.

Medical device companies lauded the plan when CMS first announced it last year. But patient-safety groups like ECRI worried it could threaten the safety of Medicare patients. Other experts agreed, and now CMS does too.

“While the rule tried to address stakeholder concerns about accelerating coverage of new devices, significant concerns persist about the availability of clinical evidence on breakthrough devices when used in the Medicare population as well as the benefit or risks of these devices with respect to use in the Medicare population upon receipt of coverage,” the proposed rule says.

The Biden administration hinted that it could decide to cover breakthrough devices in the future but that it must ensure the safety of Medicare beneficiaries.

“We believe it is important to evaluate how a device works for Medicare patients. This includes a potential decision to cover a device under Medicare in the context of collecting additional evidence (e.g., by requiring clinical trials or outcome registries) before broadly covering the device in the Medicare program,” CMS said in a news release. “Seniors and people with disabilities who make up the Medicare population often have complex medical needs and unique health considerations compared to other patient populations. This can change the potential risks and benefits of a new device for Medicare patients, specifically.” The Trump administration claimed the original rule would encourage more innovation by streamlining Medicare coverage of new devices. Under the current system, Medicare Administrative Contractors—16 in total—decide whether to cover a device within their region. Device makers must apply separately to each contractor to get coverage approval. Trump’s CMS approved the original rule in January, shortly before President Joe Biden took office. It was slated to take effect in March, but the agency delayed its implementation until December 15 to give the president’s team more time to review it.

Comments on the Biden administration’s proposal to withdraw the Trump-era regulation are due October 15.

To read more, go to Modern Healthcare.

ASA Provides Feedback on First Set of Federal Rules for No Surprises Act
September 10, 2021

On September 7, ASA sent a formal communication to Biden Administration officials in response to the first Interim Final Rule (IFR) implementing the No Surprises Act, a bill passed in December 2020 as part of the Consolidated Appropriations Act of 2021. The bill aims to eliminate surprise medical bills — unexpected charges to patients for out-of-network care — as well as help resolve payment disputes between physicians and insurers. ASA provided recommendations to ensure the law is implemented fairly and equitably.

The IFR, titled “Requirements Related to Surprise Billing; Part I,” was released in July 2021 as one of three expected rules on the No Surprises Act. ASA’s comments identified areas of improvement and communicated recommendations to Secretary of Health and Human Services Xavier Becerra, Secretary of the Treasury Janet Yellen, and Secretary of Labor Marty Walsh, leaders of the federal agencies responsible for issuing regulations to implement this legislation.

One major focus of ASA’s comments was centered on Qualified Payment Amount (QPA), a calculation drawn from in-network rates to determine patient cost-sharing for out-of network care under the new legislation. ASA urged the relevant federal agencies to clarify that QPA is a tool designed for cost-sharing purposes only and is not intended to as an accurate reflection of market conditions for health care payments, as QPA does not consider the full range and prevalence of in-network payments. For that reason, ASA believes QPA should not be given outsized weight over other factors in the Independent Dispute
Resolution (IDR) process mandated in the No Surprises Act as a backstop for prolonged payment disputes between physicians and payers. ASA called for requirements on the information provided by payers detailing how their QPA is calculated, and on determining which sources of input are appropriate for the calculation in cases of insufficient information.

ASA also recommended a measure to encourage fair and expedient payment negotiations, which would result in lower costs from decreased reliance on IDR. The measure would consist of a rule to consider a payer’s initial payment to be its final offer in IDR or alternatively consider a payer’s last offer in negotiations to be its final IDR offer.

ASA expects a second IFR on the No Surprises Act to be released within days and plans to submit comments on the forthcoming set of rules.

Read ASA’s comment letter.
Read the full text of the Interim Final Rule.

Hospital Financial Turnarounds Aren’t Waiting for the Pandemic to End
By Tara Bannow | September 7, 2021

Even as COVID-19 rages on, many health systems have strengthened their financial footing this year.

The combination of patients returning for medical care and continued government support have boosted some operating margins past 10%, a significant shift after what had been a challenging 2020. And while the ongoing COVID-19 surge has hit some states particularly hard, others aren’t seeing the same caseloads, which makes it easier for hospitals in those areas to resume normal operations.

“Some of that pent-up demand because of the uncertainties back in 2020 is coming forward in 2021 and we’re seeing that return of volumes,” said Rick Kes, a partner and healthcare senior analyst with RSM. “Obviously, that’s been good financially for the healthcare providers in 2021.”

Many of the strong performers this year so far are concentrated in the Midwest and Northeast, where COVID-19 cases are relatively less common. Rochester, Minnesota-based powerhouse Mayo Clinic posted an 11.3% operating margin in the quarter ended June 30, having generated $451 million in operating income on almost $4 billion in revenue. The Mayo Clinic’s operating margin was 3% during the same period last year.

The Mayo Clinic’s volumes in the first half of 2021 have surged from the same period in 2020, which isn’t surprising as that stretch includes the pandemic’s first wave and mandated procedure suspensions. Surgeries are up 3.4% in the first half over the same period in 2019, indicating that the company is chipping away at pent-up demand. Admissions and outpatient visits are still down from 2019, however.

To read more, go to Modern Healthcare.

When (If Ever) Will We Redesign Our Work?
By Karen Sibert, MD | September, 8, 2021

As we orient our brand-new, fresh-faced CA-1 residents to the OR, I ask this question. Has anyone explained to them that much of what they’ll need to learn in the first couple of months is how to be a nurse?

We watch them struggle to draw up propofol into a syringe without spraying white foam all over themselves. We emphasize the critical difference between a surgeon’s order of 5,000 units of heparin to be given subcutaneously or by IV. We teach residents how to inject medications into line ports using sterile technique, how to label a syringe correctly, and how to chart IV fluids and urine output.

Is this why they went to medical school?

Before a mob assembles with torches and pitchforks, let me be clear: There is much more to learn beyond these nursing and pharmacy tasks on the road to becoming a qualified anesthesiologist. But why are we still doing these tasks when other physicians don’t do likewise?

Do our intensivist colleagues mix up and inject antibiotics? Do our cardiology colleagues load infusion pumps with potassium or magnesium drips? Of course not. That would be a waste of their time and education.

It’s time to redesign anesthesia care delivery. We should be charting the course, not executing every change of sail. We should be performing the diagnostic and intellectual work of physicians all the time, not just some of the time. If we don’t, we shouldn’t be surprised if we continue to lose control over the future of our profession. It’s way too expensive to pay a physician to do the tasks of a nurse.

To read more, go to Anesthesiology News.

The Partnership Strategy Medicare Advantage Plans Are Banking On
By Nona Tepper | September 7, 2021

The booming Medicare Advantage market has become a strategic focus for major insurers and retailers to band together and grow their businesses.

Insurers partnerships are reflective on the growing population of enrollees. Over the past few years, the number of Medicare Advantage enrollees has exploded, thanks to an increasingly diverse, cost-conscious and aging population that prefers the extra benefits not offered in traditional Medicare.

The latest federal data show that 26.8 million people were covered by Advantage plans as of July, up more than 41% from 2017. During that same time, the number of those eligible for Advantage plans rose 10.3%. Approximately 10,000 Americans turn 65 every day. Anthem has said 200,000 of its existing beneficiaries reach Medicare-eligibility annually.

That’s led to big partnerships between insurers and retailers. Anthem and The Kroger Co. in July announced they planned to launch a joint Medicare Advantage plan in Atlanta, Louisville, Cincinnati and southern Virginia come 2022. Walmart teamed up with Nashville, Tennessee based Clover Health in November to offer a joint Medicare Advantage plan in Georgia, although that partnership has ended. Walmart also offers a joint, co-branded Medicare Part
D plan with Louisville, Kentucky-based Humana, which it launched in 2010.

Humana counts the second-most of Medicare Advantage enrollees in the nation; UnitedHealth Group is the largest Medicare Advantage insurer.

To read more, go to Modern Healthcare.

Healthcare Bankruptcy Filings Hit ‘Unprecedented’ Low
By Tara Bannow | September 1, 2021

When the COVID-19 pandemic hit in early 2020, many predicted a crush of healthcare bankruptcies would follow. So far, the opposite has happened.

Billions of dollars in federal, state and local aid that’s flowed to healthcare providers has led to what the law firm Polsinelli calls an “unprecedented” drop in Chapter 11 filings in an industry that’s typically among the most distressed. In fact, Polsinelli’s second quarter report shows the lowest ever recorded distress index in the healthcare industry since 2010.

It’s not just healthcare: Bankruptcies are down economy-wide, said Aram Ordubegian, a partner in Arent Fox’s bankruptcy and financial restructuring group. The simple fact is that the outflow of stimulus spending is squeezing distress out of the system—for now.

“The bubble is going to get that much bigger and when the free money flow gets turned off, we’re going to see volume back and we’re going to be busy,” Ordubegian said.

Congress approved $178 billion in grants for healthcare providers under the Coronavirus Aid, Relief, and Economic Security Act’s Provider Relief Fund, which was designed to help hospitals, medical practices and others weather the pandemic.

Providers also got $100 billion in Medicare loans and then successfully lobbied to delay the repayment deadline. The CARES Act had other perks, too, like deferred taxes.

To read more, go to Modern Healthcare.

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