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.
ACR Joins with Texas Medical Association in Declaring an Important ‘No Surprises’ Win
By Dave Pearson | February 8, 2023
The American College of Radiology is cheering a Feb. 6 decision by a federal judge in Texas who ruled that parts of the independent dispute resolution (IDR) process in the Surprise Billing Final Rule violate the Administrative Procedure Act.
The judge decided these parts make the qualifying payment amount, or QPA, the main consideration for arbitrators settling payment disputes between providers and payers over out-of-network claims.
Such weighting, the judge ruled, is out of line with the text and intent of the No Surprises Act.
In the Feb. 6 decision, U.S. District Judge Jeremy Kernodle agreed with the plaintiff, the Texas Medical Association (TMA), that defendant HHS’s rule—in the judge’s words—”… continues to place a thumb on the scale for the QPA by requiring arbitrators to begin with the QPA and then imposing restrictions on the non-QPA factors that appear nowhere in the statute.”
TMA: A major victory for patients and physicians
The TMA quickly released a statement noting that the present case was the second of four lawsuits TMA has brought against federal agencies related to rulemaking under the surprise-billing arbitration law.
In the statement, TMA president Gary Floyd, MD, calls the Feb. 6 decision “a major victory for patients and physicians. It also is a reminder that federal agencies must adopt regulations in accordance with the law.”
The decision “will promote patients’ access to quality care when they need it most,” Floyd adds, “and help guard against health insurer business practices that give patients fewer choices of affordable in-network physicians and threaten the sustainability of physician practices.”
ACR: Decision right but work incomplete
To this the chair of ACR’s board of chancellors, Jacqueline Bello, MD, adds that the victory does not affect patient protections or costs and “leaves work to be done,” as it only impacts the insurer-provider payment dispute process.
“Providers, insurers, regulators, lawmakers and other stakeholders must work together to ensure that sensible, balanced physician-informed solutions are implemented to ensure access to care as we continue to shield patients from surprise medical bills,” Bello says.
Still, with the Feb. 6 ruling, patients, and their providers “are again the winners,” Bello says, adding that ACR “will continue to work to ensure that the independent dispute resolution process complies with the No Surprises Act and is accessible, fair and efficient.”
Read the court decision here, the TMA statement here, and the ACR response here.
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.
Coming Soon to a Health System Near You: ‘Network Radiology’
By Dave Pearson | February 6, 2023
Radiology that facilitates the sharing of resources and touchpoints within an enterprise but across geographic locales is the future of the specialty, according to two Harvard radiology researchers.
Calling this practice model “network radiology,” Atul Shinagare, MD, and Ramin Khorasani, MD, MPH, both of Mass General Brigham, note the in-common resources optimally include EHR, PACS, dictation and result communication software.
Shinagare and Khorasani link their prescription for embracing such a network practice model to change in healthcare accelerated by the COVID-19 pandemic.
Up to now, they note, radiology models at large health systems typically involved operating a dedicated radiology practice at most every site in the system. “Unfortunately, this model cannot meet [growing] patient and referrer demands for high-quality subspecialized reads at all locations.”
The paper is running in the February edition of the Korean Journal of Radiology .
Under a network radiology model, patients could be scanned at any location, all the imaging studies could be pooled in a central data warehouse, and the radiologists from various locations could access these studies on shared PACS, Shinagare and Khorasani explain.
What’s more, since all networked radiologists would comprise a unified effort, they could distribute cases and work lists based on reader availability and subspecialization.
To read more, go to Radiology Business.