|Government Watchdogs Attack Medicare Advantage for Denying Care and Overcharging |
By Fred Schulte | June 29, 2022
Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday.
Witnesses sharply criticized the fast-growing health plans at a hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care, particularly those with high rates of patients who were disenrolled in their last year of life while likely in poor health and in need of more services.
Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors should not be “required to jump through numerous hoops” to gain access to health care. The watchdogs also recommended imposing limits on home-based “health assessments,” arguing these visits can artificially inflate payments to plans without offering patients appropriate care. They also called for the Centers for Medicare & Medicaid Services, or CMS, to revive a foundering audit program that is more than a decade behind in recouping billions in suspected overpayments to the health plans, which are run mostly by private insurance companies.
Related to denying treatment, Erin Bliss, a Department of Health and Human Services assistant inspector general, said one Medicare Advantage plan had refused a request for a computed tomography, or CT, scan that “was medically necessary to exclude a life-threatening diagnosis (aneurysm).”
The health plan required patients to have an X-ray first to prove a CT scan was needed. Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”
To read more, go to Kaiser Health News.
|Image Interpretation vs. Workflow Interruption: Quantified, Analyzed, Strategized |
By Dave Pearson | June 28, 2022
Upon commissioning a business process improvement team to meticulously track interpretative uptime, a 13-radiologist group learned its members had been spending nearly as many hours navigating interruptions as reading images.
What’s more, they found the interruptions measurably decreased efficiency and increased reading time regardless of imaging modality.
Corresponding author Lamya Atweh, MD, and colleagues at Nationwide Children’s Hospital in Columbus, Ohio, share lessons learned from the exercise in a study published June 27 in Current Problems in Diagnostic Radiology .
For the study, the business observers sat behind or alongside the study subjects and logged their actions into one of three columns—study interpretation, active interruption (initiated by the radiologist) or passive interruption (initiated by someone else).
Tallying the results after 61 hours of observation conducted over a three-month period, Atweh and co-authors found image interpretation claimed not a lot more than half the rads’ combined clock (52%).
The rest—close to half the tracked hours—went to active interruptions (29%) or passive interruptions (18%).
More findings of note:
Around 50% of non-interpretive time involved in-person conversations or consults. Of these, 16% involved phone calls, 67% of which were incoming.
The longest uninterrupted span was 20 minutes.
Most of the time (85%), an interruption came within the first three minutes of an interpretation. These interruptions lasted one minute or less 70% of the time.
In addition, the authors cite previous research showing the negative effects interruptions can have on interpretation accuracy. As for modality-specific findings, interruptions expanded read times by one minute for X-rays, two minutes for ultrasounds, six minutes for CTs and 10 minutes for MRIs.
To read more, go to Radiology Business.
|CMS Rethinks Limit on PET Scans for Alzheimer’s Disease Patients |
By Will Mortan | June 27, 2022
The U.S. Centers for Medicare and Medicaid Services (CMS) will take another look at its recent national coverage determination (NCD) that limits Alzheimer’s disease patients eligible for monoclonal antibody treatments to a single PET scan.
The potential revision of the NCD is based on stakeholder feedback and was “internally generated,” CMS said in a post announcing the reconsideration.
“Clinical study protocols may involve more than one beta-amyloid PET scan per patient,” CMS said.
CMS received a record 10,000 stakeholder comments and more than 250 peer-reviewed documents during the process to finalize the NCD, which was announced in April.
Currently, CMS payments cover approved drugs such as aducanumab (Aduhelm, Biogen) for Alzheimer’s disease if patients are enrolled in clinical studies approved by the U.S. Food and Drug Administration (FDA). It limits patients eligible for these trials to one beta-amyloid PET scan per lifetime.
The Society for Nuclear Medicine and Molecular Imaging (SNMMI) encouraged members to submit comments and noted it voiced strong opposition to the current NCD during the last round of public input.
“Beta-amyloid PET is the standard of care — and, in fact, the only test approved by the FDA — for detecting beta amyloid,” SNMMI said in a news release.
In stark contrast to amyloid PET scans, the current NCD explicitly covers other tests for detection of beta amyloid (e.g., cerebral spinal fluid) without limitation, SNMMI added. The public comment period associated with the reconsideration of this NCD ends July 15. The proposed decision by CMS is expected by December 16, with the final decision to be made by March 16, 2023.
To read more, go to Aunt Minnie.
|CMS to Begin New Oncology Payment Model |
By Maya Goldman | June 27, 2022
A new payment model targeted at improving Medicare cancer care will begin in mid-2023, the Centers for Medicare and Medicaid Services said Monday.
Known as the Enhancing Oncology Model, the voluntary program builds off the Oncology Care Model, which will end Thursday after six years. Two risk arrangements will be available in the new model, but both will require participants to take on some downside risk.
The Center for Medicare and Medicaid Innovation will launch the new model on July 1, 2023, for a five-year test period. The Community Oncology Alliance supports the goals of the model and looks forward to making it a success, COA Executive Director Ted Okon said in a news release. But the trade group has some concerns.
“COA is disappointed that there will remain an unnecessary one-year gap between the OCM ending and EOM beginning. During this time practices will have to shoulder the extensive investments and operational changes put in place to benefit patients without reimbursement,” Okon said.
Participating physician group practices will be responsible for patient health quality and total spending during six-month episodes of care. Participants can earn a performance-based payment—or owe CMS a performance-based recoupment if total expenditures for attributed episodes go beyond a certain threshold.
Participants will also have the option to bill for a $70-per-beneficiary monthly enhanced payment if extra services including around-the-clock access to a clinician, patient navigation services and social-needs screenings are provided to eligible beneficiaries, according to a CMS news release. CMS said it may require participants to report social-needs screening data in future model years.
CMS will pay an additional $30 per month for dually eligible beneficiaries, though only the base $70 will be included in episode expenditures. The enhanced monthly payment amount is lower than the monthly enhancement available in the Oncology Care Model, but CMS said the new amount is intended to make achieving savings easier. Okon said the alliance is concerned practices will have to take on more work and be paid less under the new system.
To read more, go to Modern Healthcare.
|Radiology Contributes Less Than Thought to the National Healthcare Spend|
By Dave Pearson | June 26, 2022
Advanced imaging is not infrequently singled out as a major and disproportionate driver of the ever-rising national health expenditure (NHE).
However, an analysis of CMS data has shown radiology had little to do with increases in Medicare costs over a 10-year period ending in 2019.
In fact, the specialty may have been disproportionately affected by cost containment policies during that period, not least by CMS’s push to achieve budget neutrality across medicine. Requirements around this goal seek to offset rising reimbursement for evaluation and management (E&M) codes by decreasing payments to providers who don’t regularly bill for E&M.
The findings and context are presented in a study published in the July-August edition of Current Problems in Diagnostic Radiology .
Researchers at University Hospitals Cleveland Medical Center and Case Western Reserve University reviewed imaging expenditures and utilization using Medicare Part B data.
The project’s prime objective was to assess trends in Medicare Physician Fee Schedule for Service (Part B) payments and utilization for imaging relative to other services from 2009 through 2019.
Findings ‘Contradict Statements’ on Imaging’s Role in the Rising NHE After adjusting dollar values for inflation and calculating price elasticity of supply and compound annual growth rates (CAGRs), corresponding author Keval Parikh MD, MHA, and colleagues found:
Throughout the analyzed 10-year period, imaging services represented a minor fraction of Medicare Part B (7%) and of NHE (0.28%). The authors note these numbers are consistent with a previous analysis.
While NHE, overall Medicare and overall Part B had positive growth rates of total expenditures, imaging did not.
Imaging had the most negative CAGR compared to all other categories, including drugs, procedures, E&M and durable medical equipment.
These findings and others the team uncovered “contradict statements that physician services and imaging are a significant contributing factor for the growth of expenditures and the disproportional amount the United States spends in healthcare compared to other countries,” Parikh and co-authors comment in their discussion.
To read more, go to Radiology Business.