High-cost Claims on the Rise, Especially Among Youth
By Jeff Lagasse | June 8, 2023
Nearly eight in 10 employers consider drug prices, high-cost claims and hospital prices a significant threat to the affordability of employer-provided health coverage for employees and their families, and high-cost claims are rising, especially among younger plan members, finds a new survey from the National Alliance of Healthcare Purchaser Coalitions (NAHPC).
Almost half describe $100,000 as the lower limit for a high-cost claim. Some use $50,000 as a threshold to identify potential high-cost claims early.
More than half the participating employers have experienced high-cost claims of $2 to $4 million in the last few years, and they’re seeing a rise in high-cost claims for younger plan members, with more than $1 million claims disproportionately weighted toward that demographic. The top conditions for these claims include cancer, prenatal/neonatal care, and treatment for COVID-19.
WHAT’S THE IMPACT
Employers have historically been more reliant on third-party administrators (TPAs) and pharmacy benefit managers (PBMs) to manage high-cost claims. As costs have escalated, employers want to learn how best to hold service providers accountable for better management, the survey found.
About 34% of employers set out-of-pocket maximums at $3,000 or below, while 42% have maximums of $3,000–$5,000. Almost 20% of employers have out-of-pocket maximums of $6,000 or more.
Most employer strategies include a focus on managing complex cases (65%) and addressing the cost of specialty drugs (64%). Other strategies employers are deploying include using a specialty carve-out; implementing a patient assistance program (PAP); case management (via TPAs); reassessing stop-loss insurance; and accessing alternative, more affordable sources of medications, such as biosimilars.
The highest priority areas for employers over the next couple years include offering precision medicine for cancer treatment (45%); implementing centers of excellence (39%); negotiating and auditing hospital prices (34%); auditing intermediaries (30%); and mitigating costs and coverage of rare diseases (30%).
To read more, go to Healthcare Finance News.
American College of Radiology, Nuclear Medicine Society Urge CMS to Fix Years-old Billing Code Mistakes
By Marty Stempniak | June 8, 2023
Two imaging groups are urging the Centers for Medicare & Medicaid Services to fix years-old coding errors that could be impacting patient care.
The Society of Nuclear Medicine & Molecular Imaging and American College of Radiology said the mistakes date to 2020, when the agency revised certain codes. The issue relates to both single-photon emission computed tomography and SPECT/CT, according to a Tuesday, June 6 news update.
ACR and SNMMI highlighted concerns about codes for procedures that are typically performed on the same day, such as radiopharmaceutical therapy by IV administration and SPECT.
“Until these retroactive changes are made, patients are not only inconvenienced but also at risk as the new guidance requires the performance of separate procedures on separate dates of service,” SNMMI noted.
The two medical groups sent a joint letter urging CMS to make modifications back in March, and SNMMI had already sent several more requesting the code changes.
The agency recently responded to clarify some of the procedure-to-procedure edits, and it made several updates, slated to go into effect for claims with July 1 or later dates of service.
SNMMI and ACR are pushing the agency to make any updates retroactive, so that radiologists and nuclear medicine specialists can still claim lost revenues impacted by the changes dating back to 2020.
“Providers should keep a listing of these claims and talk to their local Medicare contractor or payer to request manual payments,” SNMMI advised.
Read more about the issue from the society, including a list of all impacted CPT codes and procedures, here.
To read more, go to Radiology Business.
Federal Bill Would Require More Transparency From Private Equity-backed Physician Practices
By Marty Stempniak | June 6, 2023
A bipartisan bill requiring more transparency from physician practices recently advanced out of a key congressional committee.
Reps. Cathy McMorris Rodgers, R-Wash., and Frank Pallone Jr., D-N.J., introduced their Promoting Access to Treatments and Increasing Extremely Needed Transparency (PATIENT) Act on May 22. The proposal would require physician-owned practices with more than 25 doctors to report information about their business structure, mergers, and acquisitions to HHS on an annual basis. It also would apply to physician practices owned by hospitals, insurers, private equity or venture capital firms, with provider groups facing fines of $2 million for failing to comply.
“We spend more on healthcare as a percentage of our economy than any other developed nation. And for their money, Americans are rewarded with a bureaucratic and overly burdensome system,” McMorris Rodgers said in prepared remarks given at the May 24 meeting of the Energy & Commerce Committee, which she chairs. “They see the corporations responsible for providing and paying for care go to great lengths to hide costs, deny payment for care, and weigh patients down in complexity.”
H.R. 3561 was forwarded to the full House by a bipartisan committee vote of 49-0. The bill incorporates a slew of other proposed changes, including delaying $8 billion in annual Medicaid Disproportionate Share Hospital payment reductions for two years. It also would impose “billions of dollars a year” in additional site-neutral payment reductions to services provided in off-campus hospital outpatient departments, the American Hospital Association reported.
AHA called the mandatory reporting provisions tied to physician practice ownership “overly burdensome and redundant” to other existing requirements. The Association of American Medical Colleges also commented on the bill May 26, noting that several provisions will impact academic medicine.
In a June 1 news update on the bill, the American College of Radiology noted that it also calls for HHS to issue a report on consolidation trends among physician practices by 2027. The agency would then make this information available to the public.
To read more, go to Radiology Business.
Fortune 500’s Top 5 Payers
Andrew Cass | June 5, 2023
The 69th Fortune 500 was released June 5. Five payers were included in the top 25 on the annual list of the largest corporations in the U.S. ranked by revenue for the 2022 fiscal year.
Here are the top 5 ranked payers with their revenue and percentage change to annual revenue:
1. UnitedHealth Group (No. 5 on Fortune 500)
2022 revenue: $324.16 billion
Change to revenue: 12.7 percent
2. CVS Health (No. 6 on Fortune 500)
2022 revenue: $322.46 billion
Change to revenue: 10.4 percent
3. Cigna (No. 15 on Fortune 500)
2022 revenue: $180.51 billion
Change to revenue: 3.7 percent
4. Elevance Health (No. 22 on Fortune 500)
2022 revenue: $156.59 billion
Change to revenue: 13 percent
5. Centene (No. 25 on Fortune 500)
2022 revenue: $144.54 billion
Change to revenue: 14.7 percent
To read more go to Becker’s Payer Issues.
Will PET Imaging Be Covered Alongside New Alzheimer’s Drugs? CMS Dodges Topic In New Coverage Decision
By Hannah Murphy | June 5, 2023
Although many stakeholders have applauded the Centers for Medicare and Medicaid Services coverage determination regarding a new class of highly anticipated drugs that treat Alzheimer’s, some are concerned that the decision stopped short of addressing imaging related to the drugs’ use.
In a June 1 announcement, CMS indicated that the new class of drugs will be covered once they are granted the FDA’s traditional approval, with a stipulation attached that requires patients with Medicare Part B to be enrolled in registries that collect real-world data on the treatments’ effectiveness. What the announcement did not include was any mention of coverage for beta-amyloid PET imaging that is necessary for both diagnosing Alzheimer’s and monitoring the effectiveness of related treatments.
On June 5, the Medical Imaging and Technology Alliance (MITA) expressed concern over the decision to exclude guidance related to beta-amyloid PET imaging.
“Beta-amyloid PET has become a key tool in the diagnostic workup of dementia patients,” the statement reads. “There is a considerable amount of published evidence that the use of beta-amyloid imaging positively impacts patient management and leads to changes in diagnosis, even in the absence of a disease-modifying therapy.”
Eisai’s Leqembi (also known as lecanemab) is slated to be the first drug in line to receive coverage, as the FDA’s Peripheral and Central Nervous System Drugs Advisory Committee is scheduled to discuss trial results on June 9, with a possible approval to follow soon after. Lecanemab is an intravenous drug that targets amyloid—a naturally occurring protein known to disrupt cell function that has played a starring role in Alzheimer’s research for some time.
In clinical trials, Alzheimer’s patients being treated with lecanemab showed a 27% reduction in clinical decline. However, the effectiveness of such therapeutics (and any adverse effects) must be monitored via imaging.
Currently, CMS limits coverage of these vital scans to patients enrolled in a CMS-approved clinical trial under coverage with evidence development (CED). After being subjected to much criticism from experts in the imaging community, CMS announced that it would reconsider its previous coverage determination, specifically as it pertains to scan limits.
However, that determination was delayed when CMS was presented with additional clinical evidence and the timeline on when an updated decision will be made remains unclear.
To read more, go to Health Imaging.
AMA – Radiology Groups ‘Strongly Oppose’ Federal Bill That Would Expand Nurses’ Authority
By Marty Stempniak | June 5, 2023
Radiology groups and the American Medical Association “strongly oppose” a proposed federal bill that would expand advanced-practice registered nurses’ authority.
Bipartisan members of the U.S. House first introduced the Improving Care and Access to Nurses, or I CAN, Act in April. Sponsors said the bill would increase access, improve the quality of care and lower costs by allowing such nurses to practice “to the full scope of their education and clinical training.”
However, the AMA, American College of Radiology and 90 other state and national associations believe the proposal will do more harm than good.
“In general, we are deeply concerned that this broad, sweeping bill endangers the care of Medicare and Medicaid patients by expanding the types of services nonphysician practitioners can perform and removing physician involvement in patient care,” the associations wrote in a June 1 letter to leaders of the committees on Ways & Means and Energy & Commerce. “This legislation would allow nonphysician practitioners to perform tasks and services outside their education and training and could result in increased utilization of services, increased costs and lower quality of care for patients.”
In backing their claims, the AMA et al. cited a 2022 study from the National Bureau of Economic Research comparing productivity between physicians and nurse practitioners in the ED. It found that NPs ordered more tests and formal consults than doctors and sought more information from external sources such as CT scans and X-rays. NPs practicing independently actually ended up increasing costs by about $66 per emergency department visit, the physician groups wrote. Another 2018 analysis in JACR concluded that the ordering of X-rays by nonphysicians such as NPs and PAs had increased by more than 400% between 2003 and 2015.
The professional societies also cited physicians’ more rigorous training than NPs and PAs as a reason to keep the MD/DO at the center of the care team.
To read more, go to Radiology Business.
How CMS’ Reimbursement Policies Have Helped, Hurt ASCs in 2023
By Riz Hatton | June 1, 2023
CMS’ policies have the power to turn the tide of the surgery center industry. Here is how those policies have both helped and hurt ASCs in 2023.
CMS updated ASC payment rates to 3.8 percent in its 2023 “Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Proposed Rule.”In December, CMS submitted a 134-page proposal designed to improve prior authorizations for Medicare and Medicaid patients through automating the process and improving workflows. The proposal requires certain payers to address the administrative hassles of prior authorization by requiring the implementation of an automated process, meeting shorter time frames for decision-making and improving transparency.In its 2023 final rule, CMS implemented a policy that provides complexity adjustments for certain ASC procedures. According to VMG Health’s 2023 mergers and acquisitions report, these adjustments are applied to “combinations of primary procedures and add-on codes deemed eligible under the hospital [outpatient prospective payment system].” Previously, add-on codes did not receive more reimbursement when bundled with primary codes. This policy allows Medicare to provide adjustments to the payment rate to account for the costs of specific services. Hurt:
The conversion factor used to calculate physician reimbursement declined by $1.55 to $33.06 in 2023, representing a 4.48 percent decrease.In November, CMS released the Medicare payment and policy change final rule. The rule kept a 2 percent Medicare reimbursement cut to physicians in 2023, and 2024 may bring at least another 1.25 percent cut.In its 2023 final rule, CMS considered 64 recommendations for new procedures to be added to the ASC-covered procedures list, but only four procedures that are typically performed in an outpatient setting were chosen.
To read more, go to Becker’s ASC.
Radiologist Support Bipartisan Bill to Mitigate Medicare Cuts Ties to Clinical Labor Costs
By Marty Stempniak | June 1, 2023
Radiology societies are voicing their support for a bipartisan bill aimed at mitigating Medicare cuts tied to clinical labor costs.
House representatives first introduced the Providing Relief and Stability for Medicare Patients Act of 2023 on May 25. The proposal would provide relief to radiologists, radiation oncologists and other specialists stemming from updates to clinical labor prices in the physician fee schedule.
Nearly two dozen medical societies support the bill, including the American College of Radiology, Society of Interventional Radiology and the American Society for Radiation Oncology. Absent any legislative action, they’re concerned about the sustainability of procedural care provided in sites outside of hospitals and ambulatory surgery centers.
“The office setting is … critical for patient access (especially in rural and underserved areas) and can result in patients receiving care in a timelier manner,” the physician groups wrote in a May 26 letter to the legislation’s sponsors. “Unfortunately, the prolonged instability within the Medicare Physician Fee Schedule—driven by a confluence of fiscal uncertainties physician practices face related to statutory payment cuts, perennial lack of inflationary updates, significant administrative barriers, and the cumulative impact of the pandemic—is jeopardizing the financial viability of many community, office-based physician practices.”
H.R. 3674 would address this issue by providing an increase to nonfacility practice expense RVUs for procedures performed in office settings that require high-tech devices or equipment, ACR reported Thursday.
Currently, Medicare payment for clinical labor, medical supplies and equipment costs are “budget neutral,” meaning an increase in one leads to cuts for another.
The bill currently has four initial sponsors: Reps. Gus Bilirakis, R-Fla., Tony Cárdenas D-Calif., Danny Davis, D-Ill., and Greg Murphy R-N.C., who also is an MD. In a joint announcement, the quartet emphasized the importance of preserving seniors’ access to in-office procedures delivered by interventional radiologists and other specialists.
“As a practicing surgeon of over 30 years, I understand the disastrous impacts that Medicare cuts have on physicians and beneficiaries’ access to services,” Congressman Murphy, who specializes in urological care, said in a statement issued Thursday, June 1. “Due to the budget-neutral nature of the physician fee schedule, specialties with high direct costs will see overall decreases in reimbursement with increases in clinical labor wages. This inevitably results in physicians’ offices closing, increased consolidation, and ultimately, Medicare beneficiaries seeking care in a higher-cost setting.”
To read more, go to Radiology Business.