AHIP, Health Systems on Opposite Sides of No Surprises Act Debate
By Rylee Wilson | September 20, 2023
Payers and providers don’t agree on much when it comes to the No Surprises Act dispute resolution process.
In a Sept. 19 hearing held by the House Ways and Means Committee, Jeanette Thornton, executive vice president for policy at AHIP, the trade association representing insurers, said the independent dispute resolution process, or IDR, overwhelmingly favors the “initiating party,” — hospitals and air ambulance companies.
“Between an overwhelming number of disputes and repeated litigation from the Texas Medical Association that has created regulatory uncertainty and repeated starts and stops, the Departments have been hindered in developing an IDR process that works,” Ms. Thornton said in her opening statement. “The IDR process should be fair to all parties, with consistent rules, transparency into decisions, and ultimately used rarely.”
As of Sept. 1, all federal dispute resolutions are on pause after a Texas judge ruled in favor of the Texas Medical Association, which argued the dispute resolution process favors insurers.
In testimony to the committee, Jim Budzinski, CFO of Marietta, Ga.-based Wellstar Health System, said the dispute resolution process disincentivizes payers to keep health systems in their networks, instead relying on dispute resolution to receive higher payments.
“Wellstar has seen firsthand the actions by large health insurers who refuse to negotiate with us, insist on going out of network and rely on the independent dispute resolution process. We see this as a prime example of how flawed the No Surprises Act implementation has been,” Mr. Budzinski said.
Ms. Thornton said the success of the payer business model “largely depends on having large networks of high-quality, high-value healthcare.”
“The idea that health insurance providers are intentionally withholding required payments to healthcare providers defies our fundamental business model,” Ms. Thornton said. “While we advocate for a regulatory structure that incentivizes network participation over IDR, when a provider is owed additional amounts after IDR, because we aim to bring more providers in-network, we have every incentive to view that provider as a potential partner and make timely payments.”
To read more, go to Becker’s Payer Issues.
ASA’s Congressional Testimony Urges Congress to Block VA’s Effort to Remove Anesthesiologists from Veterans’ Care
September 18, 2023
ASA President-Elect Ron Harter, MD, FASA will testify tomorrow at the House Veterans Affairs Subcommittee on Health hearing titled “VA’s Federal Supremacy Initiative: Putting Veterans First?”.
In his testimony, Dr. Harter will share that: “ASA is committed to Veterans and knows that the physician-led anesthesia care team model serves Veterans best. This issue is not about what ASA wants or even what the VA Office of Nursing Services wants. The issue is what is best for the health and well-being of our nation’s Veterans, including the new PACT Act Veterans. VA has the right policy in place right now and we need the Subcommittee to continue to support it.”
Read his full submitted statement, part of which will be shared live during the hearing.
To read more, go to ASA’s website.
You can view testimony here.
Provider Groups Oppose Proposed Payment Cuts in Physician Fee Schedule
By Victoria Bailey | September 13, 2023
Provider organizations have made it clear they are not happy with the payment cuts CMS proposed in the 2024 Medicare Physician Fee Schedule (PFS). Additionally, groups have voiced concerns about proposed changes to the Medicare Shared Savings Program (MSSP), coding additions, and threshold increases in the Merit-Based Incentive Payment System (MIPS).
The American Medical Association (AMA), American Hospital Association (AHA), Medical Group Management Association (MGMA), American Medical Group Association (AMGA), and American College of Rheumatology (ACR) penned letters to CMS Administrator Chiquita Brooks-LaSure expressing their thoughts on the proposed PFS.
Opposition to payment cuts was a common theme in the letters. CMS proposed a 3.34 percent decrease to the conversion factor in 2024, reducing payment rates by 1.25 percent. Some specialties would see reimbursement increases, including internal medicine and family practices, while others would face cuts, including radiation oncology and emergency medicine.
The provider organizations said the proposed payment cuts would exacerbate workforce shortages and impact patient access to care.
“It is evident that these payment cuts are counterproductive to our shared goal of providing high-quality care to Medicare beneficiaries, and simultaneously eroding the financial sustainability of physician practices,” AMA wrote.
AHA’s letter highlighted how the reduction would hurt providers serving historically marginalized communities, especially as they continue to manage ongoing financial pressures stemming from the COVID-19 pandemic.
Similarly, MGMA called the cuts “unsustainable” and urged Congress to provide a positive update to the conversion factor in 2024.
E/M CODE G2211
CMS proposed implementing a separate add-on payment for the HCPCS code G2211. This would be used with codes for evaluation and management (E/M) visits to recognize the costs clinicians incur when longitudinally treating a patient’s single, serious, or complex chronic condition.
While most provider groups appreciated the reimbursement adjustment that accounts for clinical complexity, they requested more guidance around the change.
“For CMS to properly implement this code, the agency must further refine its utilization assumption, clarify ongoing questions surrounding utilization of the code, and share robust guidance with the provider community,” MGMA wrote.
Additionally, groups are worried about the add-on code’s impact on future conversion factors.
AMGA said it is concerned the add-on code will lead to additional across-the-board cuts, while AHA questioned the redistributive impact of the code.
To read more, go to Revcycle Intelligence.
Hospitals Call on CMS to Raise FY24 OPPS ‘Unrealistic’ 2.8% Pay Bump, Be Flexible on Price Transparency
By Dave Muoio | September 12, 2023
The Centers for Medicare & Medicaid Services’ (CMS’) proposed 2.8% pay bump for outpatient facilities is in the firing line for providers, who broadly urged the agency to reconsider its annual update methodology in light of prior years’ limited increases and persistent high expenses.
In July, CMS released its calendar year 2024 Outpatient Prospective Payment System (OPPS) proposed rule.
Headlining the proposal was a 3% hospital market basket increase and a 0.2 percentage point reduction reflecting required productivity adjustment as well as language locking in hospital price transparency requirements, among other updates.
In public comment letters submitted to the agency, groups including the American Hospital Association (AHA), America’s Essential Hospitals (AEH), the Association of American Medical Colleges (AAMC) and numerous state-level hospital associations each railed against the 2.8% increase as unrealistic and “insufficient.”
AHA, for instance, wrote that the bump “does not capture either the unprecedented inflationary environment or the other persistent financial headwinds hospitals and health systems are experiencing.”
Comments from the Illinois Health and Hospital Association pointed to a two-year, 4.5% to 5% increase in labor costs alone among its hospital membership. AEH cited an industry analysis from Kaufman Hall that showed a 4% increase in year-over-year hospital expenses as of June that is “not expected to abate anytime soon.”
The groups urged CMS to—within the limits of its statutory authority—reassess the data and methodology used to determine the annual market basket update.
The agency could begin by divorcing the OPPS market basket update from that of the Inpatient Prospective Payment System (IPPS) or by relying on “alternative cost data sources, such as Medicare cost report data, [that are] a truer representation of hospital-reported cost increases to support providing a market basket update of at least 5%,” AEH wrote.
To read more, go to Fierce Healthcare.
ASA Opposes Finalization of Duplicative, Unnecessary Evaluation and Management Code, G2211, In Response to CMS’ MPFS and the QPP Proposed Rule
September 11, 2023
Today, ASA submitted comments to the Centers for Medicare & Medicaid Services (CMS) opposing significant payment cuts to anesthesiologists while providing comprehensive and detailed solutions on a wide range of issues surrounding physician payment and the agency’s quality programs. Absent Congressional action, physicians are facing a more than 5% payment cut in CY 2024 when considering the negative update to the Anesthesia and RBRVS CFs (3.26% and 3.36% respectively) and the continued Medicare Sequestration (2%). ASA finds CMS’ proposed adoption of the Healthcare Common Procedure Coding System (HCPCS) add-on code G2211 for office/outpatient evaluation and management as a driving force behind these payment cuts.
The proposed rule highlighted how the Medicare payment system is broken and constrained by policies that consistently cause negative impacts on physician practices and clinical payment outcomes. In our comments, ASA urged CMS to use any methods within the agency’s authority to modify budget neutrality adjustments and calculate more balanced conversion factors while working with Congress to identify more permanent solutions on this issue. ASA continues to advocate for legislative stakeholders and regulatory agencies to minimize and reverse these cuts that negatively impact anesthesiologists.
ASA’s letter expressed our support for updating indirect practice expense data more frequently to reflect current costs associated with running a practice and removing frequency limitations for two critical care consultation service HCPCS codes. However, the letter asked CMS to reconsider weights of the Medicare Economic Index that would reduce the physician work component.
On the Quality Payment Program section of the rule, ASA opposed a proposal to increase the Merit-based Incentive Payment System (MIPS) penalty threshold from 75 points to 82 points, as this policy would result in over half MIPS participants incurring a penalty and disadvantage specialties like anesthesiology. ASA also urged CMS to reconsider the proposed increase of the MIPS data completeness threshold from 75% to 80% starting in the CY 2027 performance period, as the policy fails to account for physician and group reporting burdens, as well as the resource-limited anesthesia groups that use paper records. ASA encouraged CMS to build off the current measures within the Anesthesia MIPS Value Pathway and finalize ABG44: Low Flow Inhalational General Anesthesia and EPREOP31: Intraoperative Hypotension among Non-Emergent Noncardiac Surgical Cases in the 2024 anesthesia MVP.
ASA’s other QPP comments described how CMS’s MIPS topped out status policy undermines participation and program fairness. ASA also expressed our growing fears that the Total Per Capital Cost (TPCC) measure is being misapplied to anesthesia groups.
Regarding Advanced Alternative Payment Models (APMs), ASA opposed the proposed requirement that all APM participants use certified electronic health record technology (CEHRT) criteria, due to the number of practices that do not have access to EHRs or rely on paper records.
Final regulations will likely be issued in November, and unless otherwise noted, policies will be effective January 1, 2024.
Read ASA comments here.
Bipartisan Legislation Seeks to Increase Healthcare Price Transparency
By Jeff Lagasse | September 11, 2023
New bipartisan legislation intended to increase healthcare price transparency and lower overall costs for patients and employers was introduced late last week in the U.S. House of Representatives and seeks to provide patients with accurate information about the cost of procedures and services.
The Lower Costs, More Transparency Act was introduced by House Energy and Commerce Committee Chair Cathy McMorris Rodgers (R-WA), Ranking Member Frank Pallone, Jr. (D-NJ), House Ways and Means Committee Chair Jason Smith (R-MO), and House Education and the Workforce Committee Chair Virginia Foxx (R-NC).
The bill requires healthcare price information from hospitals, insurance companies, labs, imaging providers, and ambulatory surgical centers, which would be compelled to publicly list the prices they charge patients in machine-readable files. In a bid to lower costs for patients and employers, it would require health insurers and pharmacy benefit managers (PBMs) to disclose negotiated drug rebates and discounts.
On the prescription drug front, it purports to lower out-of-pocket costs for seniors who receive medication at a hospital-owned outpatient facility or doctor’s office; expand access to more affordable generic drugs; and equip employers with drug price information that could help them get a better deal for employees.
Beyond that, it also claims to fully pay for investments into programs that strengthen the healthcare system, in part by funding community health centers and supporting training programs for doctors new to their communities.
It would also preserve Medicaid funding for hospitals that take care of uninsured and low-income patients and extend funding for research to find better treatments and a cure for diabetes.
To read more, go to Healthcare Finance.
NAACOS: Medicare Payment Incentives Favor Clinicians in Fee-For-Service
By Victoria Bailey | September 8, 2023
Medicare payment incentives favor clinicians participating in fee-for-service models rather than those in advanced alternative payment models (APMs), according to the National Association of Accountable Care Organizations (NAACOS).
Advanced APMS, such as accountable care organizations (ACOs), have demonstrated the ability to generate savings for Medicare and participating providers.
To help encourage accountable care, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015, which established unified reporting systems and provided financial incentives for clinicians to join APMs.
Specifically, MACRA offered 5 percent incentive payments for clinicians in advanced APMs, which helped participants expand care teams, establish population health infrastructure, and create programs to improve care. Since MACRA was implemented, participation in advanced APMs has increased by more than 173 percent, according to NAACOS.
The 5 percent incentive payment ended in 2022 and Congress introduced a 3.5 percent extension for Performance Year 2023. Congress also provides a higher conversion factor update for clinicians in advanced APMs.
According to the NAACOS blog post, MACRA’s incentives for Payment Year 2026 and Performance Year 2024 will favor clinicians who do not participate in advanced APMs and remain in the Merit-Based Incentive Payment System (MIPS).
In 2026, MIPS clinicians will receive a 0.25 percent conversion factor update and can receive additional positive payment adjustments in MIPS. The average MIPS adjustment is typically 3 percent, meaning the total potential payment adjustment would be 3.25 percent.
Meanwhile, clinicians in advanced APMs will only receive a 0.75 percent conversion factor update. Incentives will not favor clinicians in advanced APMs again until 2032.
Despite the 3.5 percent incentive extension, the increase in MIPS adjustments calls for stronger incentives to encourage participation in risk-based payment models, NAACOS wrote. The organization urged lawmakers to support the Value in Health Care Act, which would extend MACRA’s original 5 percent incentive for two years and adjust the one-size-fits-all approach to qualification thresholds.
The blog post also noted that the $1.8 billion ACOs saved in 2022 surpasses the $644 million spent on incentives.
Congress must develop long-term solutions to incentivize participation in accountable care, NAACOS said.
Lawmakers should separate advanced APMs from MIPS and structure MIPS to incentivize participation in APMs. Additionally, they should simplify the incentive structure to account for providers serving rural and underserved populations.
To read more, go to Revcycle Intelligence.
Huge Decline in Spending on Medicare Begs the Question: Why?
By Frank Diamond | September 6, 2023
Research shows that Medicare spending has leveled off for the past decade, morphing from something that experts worried might break the federal budget to an unexpected bright spot.
The New York Times spotlighted this trend in an article this week, digging into a 2019 Health Affairs study co-authored by David M. Cutler, Ph.D., an economist at Harvard University and one of the main architects of the Affordable Care Act (ACA).
“When we first wrote about the spending slowdown, there was a lot of debate about whether it was temporary—due perhaps to the Great Recession. We didn’t think so, but it wasn’t a crazy line of thought,” Cutler told Fierce Healthcare in an interview.
Cutler said that theory has since been disproven but that “most analysts at least hedge more their outlook for spending growth in the future, even if they still see some increase above the rate in the past few years. Just as we don’t know exactly why spending slowed, we also don’t know whether it will return. But the impact on the federal budget has still been immense.”
The NYT estimates that federal spending might have been $3.9 trillion more since 2011 if spending on Medicare continued in the way that it had when experts predicted it would eventually blow a hole in the budget.
In addition, federal deficits would have been more than a quarter larger, according to the article.
Cutler’s 2019 Health Affairs study lists some legislative action that might have contributed to the slowdown in Medicare spending including the ACA, which encouraged bundled payments and accountable care organizations. However, Cutler and co-authors cited the fact that older Americans have fewer heart attacks and strokes thanks to new and fairly inexpensive medications as possibly the main reason for the spending slowdown.
“The reduction in acute cardiovascular events has been dramatic: Hospital admissions for ischemic heart disease are down 56% since 1999, and admissions for stroke have fallen by 41%,” the study said.
The Congressional Budget Office (CBO) tried to explain (PDF) in March why it overestimated Medicare spending.
“Most of the overestimate for the Medicare and Medicaid programs stemmed from an overestimate of spending per beneficiary, not an overestimate of the number of beneficiaries,” the CBO stated. “Less-than-anticipated spending for prescription drugs in Medicare Part D and for long-term services and supports … in Medicaid were two significant sources of error in CBO’s 2010 projections.”
Still, reasons for the slowdown in Medicare spending for the most part remain something of a mystery.
To read more, go to Fierce Healthcare.