Surprise Billing Ban Details Yet to Be Determined, Leaving Industry Fights to Come
By Michael Brady | March 10, 2021
Providers and insurers will continue their fight over surprise billing as federal officials figure out how to put the No Surprises Act into practice, according to experts.
The new law protects consumers from receiving unexpected medical bills resulting from out-of-network emergency care delivered by an out-of-network facility or out-of-network providers at an in-network facility. It also blocks out-of-network providers at in-network facilities from balance billing patients for non-emergency care unless they get patient consent. But patients will still be responsible for paying the in-network cost-sharing amount.
The heart of the law is a new independent dispute resolution process, which gives providers and insurers 30 days to agree to a price for the medical services delivered. If they don’t settle, they’re supposed to enter arbitration, during which each side will present a final offer and make their case for why their offer is best. The arbitrator must then pick one of the two offers. They can’t split the difference.
Congress’ decision to go with baseball-style arbitration to settle payment disputes between providers and insurers was a victory for providers since insurers’ preferred benchmarking approach would have led to lower payments for doctors and hospitals.
But the battle isn’t over yet, as federal regulators still have a lot of details to work out before the law takes effect next year.
Policymakers must recruit entities to carry out the arbitration process and provide them with guidance about how to consider a range of factors during arbitration.
To read more, go to Modern Healthcare.
House Passes COVID-19 Relief Package with Premium Assistance, Rural Health Funding
By Jessie Hellmann | March 10, 2021
The House passed a $1.9 trillion COVID-19 relief package Wednesday with several provisions beneficial to insurers and providers.
The package is a win for President Joe Biden, accomplishing large parts of his healthcare agenda only three months into his tenure.
“We are making the largest expansion of the Affordable Care Act since it was enacted and for which the Ways and Means Committee helped to write,” said Chairman Richard Neal (D-Mass.) from the House floor.
Under the bill, people with incomes over 400% of the federal poverty line qualifying for premium assistance for the first time.
Low-income Americans will also receive more generous subsidies. Both provisions, which are supported by hospitals and insurers, will be in effect for 2021 and 2022 but Democrats have signaled they would like to make the changes permanent.
The Congressional Budget Office estimated the ACA provisions could extend coverage to 2.5 million uninsured consumers at a cost of $34 billion, undoubtedly a win for insurers looking to entice younger, healthier customers and hospitals facing increasing amounts of uncompensated care.
The package will cover 100% of the costs of COBRA premiums for laid off workers through Sept. 30.
Insurer and employer groups lobbied hard for that provision, which could help more than 2 million people and cost more than $8 billion, according to the CBO.
The bill attempts to further reduce the number of uninsured Americans by offering additional funding to states that expand Medicaid to cover more low-income adults.
Twelve states have yet to accept the ACA’s Medicaid expansion, and it’s unclear how many will be motivated to do so by increased funding given the GOP’s long-held opposition to the ACA.
Rural providers will get $8.5 billion, to be distributed through the Provider Relief Fund, which Congress established last year to help providers weather the financial pressures of the pandemic.
The American Hospital Association and other hospital groups expressed disappointment that the bill didn’t include the $35 billion in additional Provider Relief Fund money they asked for.
The fund received $178 billion in previous COVID-19 relief bills.
To read more, go to Modern Healthcare.
Radiologists Grab Majority Share of Growing Lumbar Puncture Market, with More on the Horizon
By Marty Stempniak | March 9, 2021
Radiologists now deliver the lion’s share of lumbar puncture procedures among Medicare beneficiaries, with more opportunity on the horizon amid an aging U.S. population.
As recently as the early 1990s, rads’ share of the spinal tap market was as low as 10%. But a new Harvey L. Neiman Health Policy Institute analysis of the federal payment program pegged the number at 54% in 2017. During the 14-year study period, lumbar punctures per 100,000 Medicare beneficiaries leapt 25%, up to 203.4.
Study author Derek Johnson, MD, was surprised by the results; he always assumed neurologists were the go-to for lumbar punctures—a common procedure in which a needle is inserted into the spinal canal, sometimes guided by fluoroscopic imaging. Experts sees opportunity for imaging providers in these numbers.
“Radiologists are being asked to perform lumbar punctures in ever-increasing numbers,” Johnson, a neuroradiologist at the Mayo Clinic in Rochester, Minnesota, told Radiology Business Monday. “Even if the proportion of lumbar punctures performed by radiologists were to plateau now, the Medicare population is expected to increase markedly in the coming years, meaning that the absolute number of lumbar punctures performed by radiologists will almost undoubtedly increase.”
For the analysis—published this month in the American Journal of Neuroradiology—Johnson et al. analyzed Medicare claims logged between 2004 and 2017. They used a nationally representative sample to project across the payment program while also analyzing provider specialty, site of service, day of the week and patient complexity.
The numbers revealed that the portion of lumbar punctures performed by rads climbed from 37% in 2004 up to 54% by the study’s final year—a relative increase of 46%. Neurologists, meanwhile, saw their share fall from 24% down to 10% during the same time period, a relative decrease of 58%. Nonphysician providers had the largest relative increase, growing from 4% to nearly 8%.
Radiologists also remained the dominant provider in both inpatient and outpatient settings, while emergency medicine physicians rose to the top in the ED (80%). With the Medicare population projected to grow from 56 million last year up to 94 million by 2060, imaging providers should prepare to address this demand, the study authors asserted.
To read more, go to Radiology Business.
USPSTF’s New Lung Cancer Screening Guidance Lowers Starting Age
By Kate Madden Yee | March 9, 2021
The U.S. Preventive Services Task Force (USPSTF) has released an updated, final recommendation for CT lung cancer screening that lowers the starting age from 55 to 50 and adjusts smoking history from 30 pack years to 20 pack years. The final recommendation was published March 9 in JAMA.
The guidance updates the task force’s 2013 recommendation. It now states that adults between the ages of 50 and 80 who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years should undergo annual screening for lung cancer with low-dose CT. As in 2013, the task force has given the guidance a “B” grade, which translates to the following:
“The USPSTF concludes with moderate certainty that annual screening for lung cancer with low dose CT has moderate net benefit in persons at high risk of lung cancer based on age, total cumulative exposure to tobacco smoke, and years since quitting smoking,” it wrote. “The moderate net benefit of screening depends on limiting screening to persons at high risk, the accuracy of image interpretation being similar to or better than that found in clinical trials, and the resolution of most false-positive results with serial imaging rather than invasive procedures.”
For the update, the USPSTF conducted a review of 220 studies that investigated screening for lung cancer with low-dose CT, including data from the National Lung Screening Trial (NLST) and the Netherlands-Leuvens Longkanker Screenings Onderzoek (NELSON) trials. The group also commissioned a modeling study from the Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Cancer Working Group to address questions about when to start screening, the best screening interval, and the benefits and harms of different screening strategies.
To read more, go to Aunt Minnie.
Radiology Advocates Urge HHS to Reject ‘Extraordinarily Concerning’ Proposal Weakening AI Oversight
By Matt O’Connor | March 8, 2021
The American College of Radiology and other industry stakeholders recently urged the U.S. Department of Health and Human Services to strike down a last-minute proposal that would ease artificial intelligence regulations.
Under immediate-past Secretary Alex M. Azar’s “midnight” plan, seven class I devices would be permanently exempt from Food & Drug Administration premarket requirements, and possibly 83 class II devices. The FDA temporarily waived review for devices under the former category due to the COVID-19 public health emergency.
In a letter sent to federal officials on March 5, imaging advocates warned that permanently removing federal oversight for AI-backed software would jeopardize care and go against the agency’s prior plans to enhance the evaluation of tools that incorporate machine learning and AI.
The Radiology Society of North America (RSNA) and Society for Imaging Informatics in Medicine (SIIM) joined the ACR in the request.
“The proposal is extraordinarily concerning from a patient safety perspective,” ACR Board of Chancellors Chair Howard B. Fleishon, MD, MMM, said in the document. “Although we do not anticipate implementation by the current administration, informatics experts must inform regulators of the potentially harmful impacts resulting from this idea in case the proposal resurfaces.”
A number of class II devices are used by physicians and radiologists during imaging-driven care, including a lung CT computer-aided detection system, triage and notification software, imaging processing applications, and cancer-detection tools, among many others.
ACR leadership encouraged the FDA to beef up its artificial intelligence oversight to enhance real-world capabilities. This should include multisite validation, monitoring longitudinal performance, and other measures, the letter writers argued.
“The priority of the FDA in this space must be to ensure safety and effectiveness—effectively doing so will ultimately help establish trust and promote clinical adoption of AI/ML-enabled innovations,” said Bibb Allen Jr., MD, chief medical officer of the ACR Data Science Institute.
Read the entire March 5 letter here.
Scaling Up Radiology Resources Could Avert 9.5M Deaths While Saving Trillions, Global Imaging Leaders Charge
By Marty Stempniak | March 5, 2021
Comprehensively scaling up radiology resources across the planet—coupled with investments in treatment and quality—could save some 9.55 million lives over the next decade, global imaging experts charged on Thursday.
The finding is part of a groundbreaking new report supported by more than two dozen worldwide leaders in this space. Their aim is to reframe the debate so that cancer imaging is placed alongside curative interventions as an essential component of care, those involved say.
Members of the Lancet Oncology Commission on Medical Imaging and Nuclear Medicine have produced what they believe is the first-ever comprehensive quantification of global imaging resources. As part of the endeavor, a simulation model built by Harvard University estimated that investing in imaging and treatment could produce a net benefit of $2.66 trillion and net return of $12.43 on every $1 spent.
“For the first time, we have evidence demonstrating the substantial health and economic benefits of scaling up imaging and nuclear medicine access for health outcomes of cancer patients globally,” Rifat Atun, MBBS, MBA, the report’s co-first author and a professor of global health systems at Harvard, said in a statement, adding that their findings make a “compelling economic case” for international imaging investment.
Atun and colleagues’ goal is to convince governments and other funding bodies to put resources toward radiology, with an emphasis on low- and middle-income countries. By 2030, worldwide cancer deaths could reach 13 million annually, they estimated. About 80% of disability-adjusted life years lost to the disease occur in such under-resourced countries, which receive only about 5% of global funding for cancer care and control.
The commission’s March 4 report concludes that achieving this “equitable scale-up” is a matter of vision and political will. Effective public leadership, active participation from myriad stakeholders, and aligned global efforts to expand access are just a few of the essential ingredients to reaching their desired endpoint, leaders said.
Twenty-seven organizations are supporting the commission, including the RSNA, the Society of Nuclear Medicine & Molecular Imaging, the American Society for Radiation Oncology, and the American College of Radiology. The latter called the report “groundbreaking” on Thursday, noting that the college has long supported these aspirations.
“The ACR invested in the formation of this effort and strongly supports the goals that the commission has laid out,” CEO William Thorwarth, MD, said in a statement.
You can read commission’s full report, which was launched at the 2021 European Congress of Radiology on March 4, in Lancet Oncology here.