ACR Sounds Alarm as 1st Insurer Uses No Surprises Act to Carve Out Docs Who Won’t Accept ‘Drastic’ Cuts
By Marty Stempniak | December 2, 2021
The American College of Radiology sounded the alarm Wednesday following news of the first health insurer using surprise billing legislation to cut off payments to providers who won’t accept “drastic” pay cuts.
Blue Cross Blue Shield of North Carolina began circulating a letter to physician groups last month, noting the impending Jan. 1 start date for the No Surprises Act. Whereas the insurer previously contracted with providers charging what it deemed “an inflated rate,” the local Blue Cross is now seeking a “significant reduction” in what it pays certain “outlier” providers. Those who do not comply will face “terminations” of their contracts.
The college called the move “profit driven” and believes many physicians, already reeling from the pandemic, cannot withstand such reductions.
“Without regard for patient impact, insurers are trying to increase their already record profits by narrowing their provider networks,” Howard Fleishon, MD, chair of the American College of Radiology Board of Chancellors, said Dec. 1.“
The American Society of Anesthesiologists also expressed “grave concern” following BCBS of North Carolina’s “strong-arm tactics,” and said the payer has sought to cut reimbursement anywhere from 10% to 30%. The insurer has about 3.81 million members in the Tar Heel State, according to its website.
Lawmakers first enacted the legislation in late 2020, banning the practice of sending patients surprise medical bills and establishing a third-party process to settle payment disputes. Physician groups such as the ACR have said they support the thrust behind the effort but believe the Biden administration is failing to honor congressional intent in its rollout. Meanwhile, Health and Human Services Secretary Xavier Becerra defended the policy last month.
The Texas Medical Association filed suit in late October to stop the interim final rule from moving forward, and Fleishon said ACR is now “strongly considering” doing the same. Provider groups are particularly concerned about the weight placed on the “qualifying payment amount” in settling disputes with insurers. The college sees this as the primary factor in the process, and one that payers can wield to set “artificially low” benchmark payments.
Physicians are also concerned that savings will go straight into the pockets of already-flush insurance companies.
“Record insurer profits have not led to reduced premiums for beneficiaries,” the ACR said in its statement. “There is no indication—nor proof—that insurer profit increases gained via No Surprises Act-related network restrictions would result in lower costs to patients.”
To read more, got to Radiology Business.
Radiologists Discover ‘Startling’ Disparities Between Commercial, Medicare Imaging Prices
By Hannah Murphy | November 30, 2021
The hospital price transparency rule went into effect this past January, but a new dive into the numbers revealed low compliance rates, as well as “startling” variations between commercial and Medicare rates for diagnostic radiology exams.
The research paper, published Tuesday in Radiology, unveiled a slew of curious figures for imaging services. In some situations, a private payer rate came in 10 times higher than a Medicare rate for an exam with the exact same CPT code. This, in addition to hospital compliance, or lack thereof, was cause for concern for Howard P. Forman, MD, MBA, with Yale University’s School of Medicine.
“The results are at once unsurprising and startling. Price transparency has always been a challenge for healthcare. However, one would expect that the force of federal law would induce compliance,” Forman wrote in an editorial published alongside the analysis.
Experts examined the 13 CMS-specified shoppable diagnostic radiology services included under the federal law, along with disclosed negotiated prices for these exams across 5,700 hospitals (94% of all U.S. hospitals).
Researchers discovered that the vast majority of U.S. hospitals are not in compliance with price transparency stipulations, with only 36% adhering. Just as concerning, Forman noted, is that median negotiated prices for commercial versus Medicare rates often differed substantially for the exact same exam.
CT scans of the brain or head, for example, had the highest median negotiated price range for Medicare at $813 versus $137, while mammography had the lowest variance. On the commercial side, contrast-enhanced CT scans of the abdomen and pelvis had the greatest range.
“Why should performance, not the interpretation, of a single brain CT examination vary by 10-fold between the lowest and highest negotiated rates?” Forman questioned. “If there is more value in one imaging study than another identical one, then ask yourself why.”
As hospitals eventually begin to comply with transparency laws, the authors caution that patients will be armed with the freedom to choose where to spend their money. This, they noted, may negatively impact some markets, particularly academic practices.
“This will not stop at price discovery. We will likely be required to report on quality, too. We would do well to be prepared,” Forman warned.
Some States have 25% Fewer Radiologists than Medicare Patients, Illustrating Nationwide Trend
By Matt O’Connor | November 30, 2021
The population of Medicare beneficiaries has outpaced the number of radiologists entering the workforce over recent years, leaving some states with nearly 30% fewer providers compared to patients who demand imaging services.
U.S. census data from last year shows the 65-and-up population grew by 15 million since 2010, compared to a smaller 2.5% jump in diagnostic radiology trainees entering the workforce during that same time period.
“From these two points we can begin to ask some deeper questions about the supply and demand of radiology to this population,” Aditya Khurana, MD, an incoming radiology resident at the Mayo Clinic in Rochester, Minnesota, explained Wednesday morning during the RSNA annual meeting.
For answers, Khurana turned to Medicare Part B claims data and imaging service figures taken from the Kaiser Family Foundation—each spanning 2012 through 2018.
Both diagnostic radiology and the population of Medicare beneficiaries grew during the study period (4.4% and 7.4%, respectively), which has led to a national supply and demand mismatch for radiologist labor of about 3%.
Looking at geographic differences in these growth rates, however, reveals that many regions are struggling with steeper supply and demand issues.
Across the West, for example, the rise in Medicare beneficiaries has outpaced rads by 10.1%. But in the South, diagnostic radiologists are more prevalent (3.4% mismatch rate). The Northeast has 0.9% more Medicare participants than rads while the Midwest is almost even at a 0.1% surplus of radiologists.
At the state level, Hawaii boasted the largest undersupply of radiologists at 26.7%, while Minnesota had a 28.5% oversupply compared to their Medicare population.
Importantly, some regions and states, such as Alabama, saw growth in both categories but, as is the case here, the sharp rise in the number of Medicare beneficiaries (10.8%) overshadowed the steady rise in radiologists (3.4%), leading to a rad supply shortage.
Khurana, who won the Medical Student Trainee Research Prize for his work, said he is planning to extend his analysis to DBT-level mismatches between urban and rural populations. He noted his current results should be useful for forecasting future workforce trends.
“This state-level data offers a baseline for future studies and can allow for even more questions using other data,” Khurana added during the session. “Once areas of undersupply are identified we can start to prepare for the future and make sure that these areas aren’t forgotten in the next wave of clinical radiology.”
To read more, go to Health Imaging.
Cuts Systematically Dismantle Access to Quality Care
Op-ed By Mark Isenberg | November 29, 2021
Dear Members of Congress:
Death by a thousand cuts is systematically dismantling access to quality healthcare.
As most clinicians will tell you, it isn’t just one medical issue that impacts a patient’s holistic health, but a myriad of afflictions—the cascading impact of multiple ailments—that left unaddressed can inevitably cause systematic failure. Hyperbolically speaking, the current patient is quality healthcare, specifically patients’ access; more specifically, the rural patient’s access, and the corresponding danger of the lack of access. (Sounds like Medicare for all— “rights” are akin to those granted in the Bill of Rights, the Constitution, or the law—and aside from the emergency department, there are no “rights” to healthcare).
Thousands of Baby Boomers are joining the ranks of Medicare (estimated at over 10K per day). To keep up with the demand for healthcare, we need a frontline ready to handle their needs across a multitude of specialties, in urban and rural settings. However, clinicians and healthcare facilities all over the nation are facing significant reimbursement cuts at a time when they are still trying to recover from the ongoing Public Health Emergency (PHE). In a pre-pandemic working paper, the National Bureau of Economic Research (NBER) found that rural hospital closures increased community mortality by about 5.9 percent overall, while urban hospital closures had no measurable impact on mortality.
With the Medicare Physician Fee Schedule (MPFS) release on November 2, 2021, physicians across the board will face -9.75% in Medicare cuts in 2022, barring any last-minute legislative recourse. Some medical specialties will face even deeper cuts. This is the result of a perfect storm: sequestration (-2%), PAYGO (-4%), and the MPFS (3.75%) hitting clinicians all at once. Nothing says thank you to the healthcare community for fighting on the frontlines during a pandemic, like a significant pay cut. (Take action now and tell Congress to stop the cuts.)
Recently, Representatives Bucshon (R-IN) and Bera (D-CA) introduced bipartisan legislation (H.R. 6020: Supporting Medicare Providers Act of 2021) that would extend the 2021 Medicare physician payment adjustment of 3.75%. This would be a welcome reprieve, but it won’t stop the bleeding. (Join advocates across the country in urging Congress that our frontline healthcare workers deserve our support during this healthcare crisis, so they can continue to keep our communities safe and healthy.)
With the recent passing of the No Surprises Act – Interim Final Rule Part II, physicians were dealt yet another blow. This rule justifiably helps take the burden of surprise medical bills off the patient’s shoulders; however, it severely limits physician groups’ ability to negotiate a commercially “reasonable” rate with carriers. Additionally, a deeply flawed Independent Dispute Resolution (IDR) process heavily favors the carriers by “weighting” the Qualified Payment Amount (QPA), essentially putting doctors’ ability to seek fair reimbursement on life support.
We see commercial carriers forcing reduced rates with current in network physicians or sending termination letters to others. This was always their goal: reduce what they must pay to in network groups—surprise billing was merely the Trojan horse they used to convince lawmakers. We do not need to look any further than the California state system, which similarly tilts the balance so strongly in favor of the health plans. According to the CA Medical Association pre-COVID survey and the American Society of Anesthesiologists member survey, both showed that an unlevel playing field will have dire consequences for patients’ access to care.
Most health insurers, after achieving record breaking earnings in 2020, during a once-in-alifetime pandemic, have announced that they are raising their premiums again in 2022−along with declining contract rates for physician practices, hospitals, and other healthcare facilities. Since the PHE is ongoing and many elective procedures are restricted, this is essentially pulling the plug on clinicians and healthcare facilities, making any future recovery questionable.
With all of these “injuries,” how can access to care be assured, particularly in the rural and underserved areas? While on the surface, this appears to be a financial issue—it becomes an access to care issue. Why would physician groups facing Medicare cuts and reduced commercial rates drive to rural areas to provide services? They are not compensated for their travel time, their costs continue to rise, and their revenue is set to decline in 2022.
Perhaps a more important question is, if healthcare clinicians and facilities can no longer pay their employees or keep the lights on, how can the rural and underserved communities receive the quality healthcare relied on by millions of Baby Boomers and families? With health equity a pillar of the Biden Administration, surely, they are aware that this simple economic equation will regrettably play out throughout the nation.
Unfortunately, this new “normal” that we all are trying to navigate has become overwhelming. It is important to revise the strategy NOW, not years down the road when rural hospitals are closing left and right and already overwhelmed urban facilities don’t have staff or capacity to provide quality healthcare—then it will be too late. Where is the equity in that scenario?
We ask that you consider co-sponsoring or voting for H.R. 6020. Your support will give healthcare a fighting chance, enable patients with quality healthcare in their communities, and grant time to find a better solution, ensuring health equity now and for generations to come.
Published in Becker’s Hospital Review.
Patient Access to Imaging Doesn’t Overburden Radiologists—Many See It As Key to Transparency
By Matt O’Connor | November 28, 2021
Granting patients access to their imaging results through an online portal doesn’t significantly add to radiologists’ workloads. In fact, many view the change as a crucial step toward more transparent medicine.
The 21st Century Cures Act, which seeks to bolster interoperability, includes a provision ensuring patients immediate access to their clinical information, including radiology reports. But some experts are wary that instant results may confuse patients and increase the demand on overworked physicians.
New research shared Sunday at the RSNA annual meeting, however, puts some of those concerns to rest.
Out of more than 250 radiologists participating in programs granting patients access to their images, 76% said the practice had no impact on their role. Seventy-one rads viewed web based image access as a positive step toward transparency while 17 noted workflow adjustments are still needed.
“These results highlight that our patients are tech-savvy, active and informed consumers of healthcare,” Hailey Choi, MD, an assistant professor of Clinical Radiology at the University of California, San Francisco, said during the presentation. “We believe our work provides valuable insight and highlights some need for future workflow modifications and patient directed tools.”
For the study, Choi and her colleagues set out to assess how often patients actually view their images and how this affects radiologists.
Three academic organizations participated, launching an EHR-based portal at different time points. Shared exams ranged from point-of-care imaging and radiographs to breast exams and endoscopic results, among many others.
Each site first gathered patient-use data between September 2020 through February 2021. Radiology trainees and faculty then responded to an anonymous survey gauging their experiences, which was performed from January-March 2021. Overall, more than 1.6 million radiology exams were included, with 234,000-plus or 14.2% viewed by patients.
More than 63.8% of respondents were never approached with imaging concerns, according to the survey results. And among the 33.9% who were contacted by patients, most said such frequency only reached 3-4 times each year.
A number of radiologists opted to leave free-text comments in their survey. Nearly half mentioned that patients “have a right to healthcare transparency,” followed by concerns regarding patient confusion and anxiety (30% of comments).
Choi noted the study is strengthened by its multi-institutional design and is the first to assess radiologists’ perspective on granting patients access to their images. At the same time, they didn’t survey patients nor assess if image access impacted clinical outcomes.
To read more, go to Health Imaging.
States Tell Justices Medicaid Should Have Access to Members’ Legal Settlements
By Nona Tepper | November 24, 2021
Fourteen states on Monday urged the U.S. Supreme Court to allow Medicaid agencies access to any portion of enrollees’ legal settlements intended to go towards their medical bills.
In an amicus brief led by Ohio and Utah, the Republican states argued Medicaid must be able to collect from any portion of a tort settlement representing payment for medical services, whether its future expenses or past treatment.
The justices are scheduled to hear arguments on the issue in January, and their decision will set the standard for state Medicaid programs nationwide.
To read more, go to Modern Healthcare.
HHS Chief Defends Controversial Surprise Billing Provision, Urging Docs to ‘Tighten Their Belt’
By Marty Stempniak | November 24, 2021
Health and Human Services Secretary Xavier Becerra is defending a key provision in a recently released rule to address surprise medical bills, which is opposed by radiologists and other physicians.
The federal government is proposing to ban the practice of issuing unexpected IOUs for out of-network care. Physicians have said they support the effort. But they’re concerned HHS and other agencies are ignoring Congressional and favoring insurers by making the “qualifying payment amount” the crux of such payer-provider negotiations.
Becerra defended the final rule Monday, emphasizing HHS’ intent is to protect patients and drive down prices.
“I don’t think when someone is overcharging, that it’s going to hurt the overcharger to now have to [accept] a fair price,” he told Kaiser Health News. “Those who are overcharging either have to tighten their belt and do it better, or they don’t last in the business.”
The American College of Radiology and numerous other doc groups have advocated for using several factors to settle disputes, beyond the QPA (generally, the median contracted rate for services in a geographic area). Quality of outcomes, market share, complexity of services, case mix, and prior contract history are a few suggestions. More than 150 members of Congress are pressuring the administration to adopt this approach, alongside tens of thousands of physicians.
But Becerra is concerned broadening the process too much could increase costs. He highlighted a recent HHS report, which found that states using an approach similar to what physicians are recommending have seen healthcare costs rise.
“When the arbitration process is wide open, no boundaries, at the end of the day healthcare costs go up, not down,” Becerra told the news site. “We want costs to go down. And so, we want to set up a system that helps provide the guideposts to keep us efficient, transparent and cost-effective.”
The interim rule is slated to go into effect on Jan. 1. Rules this far along in the process are rarely changed, Kaiser Health News reported, but Becerra said HHS will continue listening. Read more from the interview below.
To read more, go to Radiology Business.