‘More Good News’: Humana Reverses Controversial Coverage Restrictions for PET/CT Exams
By Matt O’Connor | June 22, 2021
One of the nation’s largest commercial insurers has reversed its policy restricting payment for certain PET/CT and SPECT/CT exams following criticism from nuclear medicine groups and providers.
Humana’s medical review panel met at the end of May and decided to change course, now reimbursing PET/CT scans for certain cardiac and neurologic indications along with SPECT/CT exams. Imaging experts and nuclear medicine groups have lambasted the insurer for denying coverage on the grounds such exams are “experimental” and “investigational.”
The Society of Nuclear Medicine and Molecular Imaging, which has been pushing for the change, said the new determination is “generous” and aligns with national coverage guidelines for 18F FDG-PET regarding infection and inflammation.
“We are grateful Humana took our concerns seriously and look forward to working together to expand SPECT/CT coverage,” SNMMI said in an announcement published Monday.
While Humana’s policy is only a draft document, it details coverage determinations for myocardial assessments, suspected prosthetic valve endocarditis, and SPECT/CT and PET/CT for neurologic indications.
Back in November, the Louisville, Kentucky, payer first announced its restrictions for most hybrid molecular imaging situations. The move quickly drew the ire of SNMMI and the American Society of Nuclear Cardiology, among others.
This past April, Humana gave some ground, announcing it would no longer deny coverage for PET/CT imaging of gastric and esophageal oncologic indications.
To read more, go to Health Imaging.
CMS Offers $20M in Grants to Help State-run ACA Exchanges Make Improvements
By Robert King | June 22, 2021
The Biden administration is offering $20 million in grants to help states improve their Affordable Care Act insurance exchanges.
The funding announced late Monday and provided by the American Rescue Plan Act is intended to help state-run exchanges modernize or update systems or technology to meet federal requirements.
“This funding available to states will help them to provide consumers with swift eligibility determinations and enrollment into comprehensive healthcare plans,” said Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure in a statement.
Currently, there are 13 states and the District of Columbia that run their own exchanges. There are another six states that have their own exchanges but use the federally run HealthCare.gov for open enrollment and subsidy eligibility. The remaining states rely on HealthCare.gov and do not have their own exchanges.
The funding will award 21 cooperative agreement grants to the currently approved state-run exchanges, even those that use HealthCare.gov for eligibility and enrollment.
“SBMs can prioritize funding to make modifications to systems or technology infrastructure related to the implementation of application federal requirements,” CMS said in a release.
The new funding comes as exchanges have had to implement newly enhanced tax subsidies passed under the American Rescue Plan. The enhanced subsidies are scheduled to expire after the 2022 coverage year, but Congress is considering making the boost permanent.
Exchanges can use the funds to help make consumers aware of the new subsidies, including creating more consumer notifications, education, stakeholder training or other support activities.
State exchanges have until July 20 to apply for the funding, which CMS anticipates doling out in September.
To read more, go to Fierce Healthcare.
Do Radiologists Need to Manage Patient Expectations of AI?
By Kate Madden Yee | June 22, 2021
As artificial intelligence (AI) continues to be developed and incorporated into healthcare, radiologists should consider how the technology’s promise is being presented to the public — and manage their expectations about when it will be standard of care, according to an opinion published June 17 in the Journal of the American College of Radiology.
The need to set this context for patients is driven in part by how the media communicates about the technology, wrote a team led by Edmund Weisburg of Johns Hopkins Medicine in Baltimore.
“As the medical community incorporates deep learning and AI into some specialties, particularly emergency radiology, it may be prudent to ponder if we are on the cusp of unrealistic public expectations regarding the use of AI in routine radiologic diagnosis,” the researchers wrote.
So how close is the use of AI as standard practice in radiology? Weisburg’s group cited a study that found no significant difference between radiologists and AI in identifying pleural effusions, concluding that “AI demonstrates great potential for assisting radiologists in evaluating supine radiograph results and decreasing the volume of missed findings.”
The team also highlighted a 2020 survey of chest radiologists and computer scientists that found both groups to be bullish about AI’s influence in radiology (although about 15% of the
computer scientists thought that would also mean that radiologists will be obsolete in a few decades).
How do patients feel about AI and radiology? Weisburg and colleagues cited another study that found patients to be more comfortable with a radiologist first reader and an AI second reader, rather than a standalone AI interpretation. And results from research that consisted of a questionnaire given to people in a fracture clinic showed that 95.4% of patients preferred a clinician to resolve unclear reading results rather than AI.
In any case, using AI for diagnosis of disease is far from the standard of care, and patients may not understand that.
To read more, go to Aunt Minnie.
Hospital Reduces Radiology Reporting Disruptions; CT Wait Times With Simple Practice Tweak
By Marty Stempniak | June 22, 2021
One radiology department is finding success reducing both interruptions during reporting and patient wait times with a few minor practice tweaks, according to a study published Monday.
Chelsea and Westminster Hospital particularly experienced starts and stops during the vetting of plain computed tomography head scans and CT of the urinary tract. But by taking these tasks off radiologists’ plates, the 430-bed London teaching hospital saw incoming calls drop 30% for head scans while wait times fell 40%.
“Reducing disruptions during radiology reporting has the potential to improve radiologists’ ability to manage workload, job satisfaction, stress levels, efficiency, reporting accuracy and therefore patient safety,” lead author Christopher Watura, a musculoskeletal radiology fellow with the National Health Service at the time of the study, and colleagues wrote June 21 in Current Problems in Diagnostic Radiology. “Radiology has a pivotal role in most in-patient care pathways and so smoothing scanning bottle necks is expected to contribute to improved service effectiveness, including reduced patient length of stay.”
To reach their conclusions, Watura and colleagues conducted a prospective investigation, identifying head and urinary tract CTs as two of the most common reasons for phone calls. Radiology registrars recorded all incoming calls into a spreadsheet during one-week periods in September and January. Clear protocols exist for these two exams, the authors noted, which do not routinely require a radiologist to weigh in.
Chelsea and Westminster Hospital shifted to having radiographers directly accept these requests, both during regular business hours and afterward. (Previously referring providers needed to discuss the scan with both a radiologist and radiographer.) Tracking volumes after the change, Watura and colleagues found a 30% drop in calls to vet head CT and a 100% decrease for urinary tract scans. Overall calls reduced by 10%, while scan vetting check-ins dropped 34%, and the number of both types of scans remained stable after the change.
The hospital next plans to expand the intervention to other tasks that rads are frequently phoned for but could be completed by other team members.
To read more, go to Radiology Business.
House Bill Would Ban Arbitration Clauses in Insurance Contracts
By Jessie Hellmann | June 18, 2021
A bill introduced Thursday by House Democrats would prohibit forced arbitration clauses in health insurance contracts that prevent customers from suing over denied claims.
These clauses require patients go to a private arbiter to settle disputes with their insurance companies, but Democrats argue that practice is unfair.
“Right now, health insurance giants are using mandatory arbitration to escape accountability when they cheat patients and deny them coverage of the care the law requires,” Rep. Katie Porter (D-Calif.), the bill’s sponsor, said in a statement.
The bill, which has four Democratic cosponsors, would prohibit the inclusion of mandatory pre-dispute arbitration clauses and clauses limiting class action lawsuits in health insurance contracts.
Porter cited a report from Public Citizen, a consumer rights group, that claims a growing use of binding, pre-dispute arbitration clauses.
The report argues that insurance companies use the clauses to “immunize” themselves from lawsuits over consumer fraud, denials of treatment in managed care and “unfair” claims settlement practices.
“This important legislation protects patients from being forced to sign away their rights in the fine print of a contract when they should have the right to seek judicial relief if an insurer illegally denies coverage, refuses to provide required notice and appeal rights, fails to provide required premium rebates, or otherwise acts in bad faith,” said Rep. Lloyd Doggett (D-Texas.), chair of the House Ways and Means Health Subcommittee.
Arbitration is typically cheaper than litigation and can take less time. But opponents say forced arbitration gives companies an unfair advantage over consumers and workers.
To read more, go to Modern Healthcare.
Congressional Democrats Hope to Expand Coverage in Medicaid, Medicare This Year
By Jessie Hellmann | June 18, 2021
Congressional Democrats are hoping to pass a slew of healthcare priorities later this year aimed at expanding access to coverage and making it more affordable for patients.
There appears to be a broad agreement on the types of healthcare policies that should be in the package, like closing the Medicaid coverage gap and adding dental and vision benefits to Medicare, but details are still being ironed out by committee staff and congressional offices and nothing is certain.
The stakes are high for Democrats who view this as their last chance to accomplish major healthcare reform before the midterms, in which their majorities in the House and Senate are on the line.
“I think there is a common denominator around what people want and a growing alignment around expectations,” said Eliot Fishman, senior director of health policy at Families USA, which advises Democrats on issues like the ACA and Medicaid.
House and Senate Democrats are hoping the package will close the coverage gap in non-Medicaid expansion states, add dental and vision benefits to Medicare, permanently expand ACA subsidies to middle-income earners, lower deductibles in the marketplace, lower drug prices, expand access to home-and-community based services and address maternal mortality.
They’re likely to use reconciliation – a budget maneuver that only needs 50 votes to pass and can’t be filibustered – but for it to work, all Democrats must be on the same page – a heavy lift for the narrow House and Senate majorities.
The current thinking is Congress will pass a bipartisan bill focused on “hard” infrastructure, like roads and bridges, followed up with a Democrat-only reconciliation bill that fulfills key parts of President Biden’s so-called “jobs” and “families” plan.
“There’s no unity or consensus yet, but there is a facsimile of that – there’s an agreement of the contours of what it’s going to look like,” said Alex Lawson, executive director of Social Security Works, which works with progressive Democratic offices on issues like drug pricing and Medicare expansion. Here are some of the provisions that could end up in a reconciliation bill, which Democratic leaders hope to pass this fall.
To read more, go to Modern Healthcare.