Surprise-billing Rule ‘Puts a Thumb on the Scale’ to Keep Arbitrated Costs in Check
By Julie Appleby | October 14, 2021
Patients are months away from not having to worry about most surprise medical bills — those extra costs that can amount to hundreds or thousands of dollars when people are unknowingly treated by an out-of-network doctor or hospital.
What’s not clear is whether the changes in law made by the No Surprises Act — which takes effect Jan. 1 — will have the unintended consequences of shifting costs and leading to higher insurance premiums.
Probably not, many policy experts told KHN. Some predict it may slightly slow premium growth.
The reason, said Katie Keith, a research faculty member at the Center on Health Insurance Reforms at Georgetown University, is that a rule released Sept. 30 by the Biden administration appears to “put a thumb on the scale” to discourage settlements at amounts higher than most insurers generally pay for in-network care.
That rule drew immediate opposition from hospital and physician groups, with the American Medical Association calling it “an undeserved gift to the insurance industry,” while the American College of Radiology said it “does not reflect real-world payment rates” and warned that relying on it so heavily “will cause large imaging cuts and reduce patient access to care.”
Such tough talk echoes comments made while Congress was hammering out the law.
The most recent guidance is the third issued to implement the law, which passed in late 2020 after a years-long battle. It was signed by then-President Donald Trump.
The No Surprises Act takes aim at a common practice: large, unexpected “balance bills” being sent to insured patients for services such as emergency treatment at out-of-network hospitals or via air ambulance companies. Some patients get bills even after using in-network facilities because they receive care from a doctor who has not signed on with an insurer’s network.
Patients were caught in the middle and liable for the difference between what their insurer paid toward the bill and the often-exorbitant charges they received from the provider.
Once the law takes effect next year, patients will pay only what they would have if their care had been performed in network, leaving any balance to be settled between insurers and the out-of-network medical providers. The law also gives insurers and providers 30 days to sort out discrepancies.
To read more, go to Kaiser Health News.
Physician Groups Warn Nearly 10% in Medicare Cuts Could Stall Shift to Value-based Care, Force Staff Cuts
By Robert King | October 13, 2021
Several medical groups say a new round of cuts to Medicare payments set to go into effect in 2022 will derail their move to value-based care and impact hiring of new staff.
Medical groups spoke about the need for Congress to avert a series of cuts during a briefing on Tuesday sponsored by the American Medical Group Association (AMGA), which represents specialty medical groups.
“On heels of public health emergency to be dealt this blow it does feel a little bit like ‘death by a thousand paper cuts,’” said Carol Brockmiller, CEO of Quincy Medical Group, a group of more than 150 doctors, during the briefing.
Providers are facing 9.75% in cuts to Medicare reimbursements in the next year. This includes 4% in cuts due to go into effect under the PAYGO law, which calls for Congress to install a series of cuts across the federal government if spending reaches a certain threshold.
Congress also temporarily increased physician payment rates by 3.75% last year to help physicians offset financial shortfalls caused by the pandemic.
The Centers for Medicare & Medicaid Services also proposed to reduce the physician fee schedule conversion factor by 3.75%, but that increase is expected to go away after this year. Congress issued a moratorium last year to pause a 2% Medicare cut imposed under sequestration. Currently, the moratorium is expected to run through 2021, but a bipartisan infrastructure package that passed the Senate in the summer would resume the cuts to help pay for the roughly $1 trillion package.
Medical group leaders said if all the cuts go through, it could take years to fully recover. “What are the things that you would cut in the short term and what are the longer-term initiatives planning to put in place to continue to deliver healthcare,” asked Scott Hines, M.D., chief quality officer for the group Crystal Run Healthcare.
Group leaders said the push to value-based care would likely be on the chopping block. “We have done everything that has been asked of us to try to move towards value, and it has cost money,” said Brockmiller. “To be in that defensive position as opposed to a proactive [position] changing the paradigm of healthcare as a result of costs … it’s not where any of us should be spending our time.”
A survey conducted of 92 AMGA members also found that if the cuts were to go into effect, 42.7% will install hiring freezes and 36.8% will eliminate services. Another 22.2% will no longer accept Medicare patients.
To read more, go to Fierce Healthcare.
Updated Lung Cancer Screening Guidelines Could Spell 54% Surge in LDCT Imaging Eligibility
By Marty Stempniak | October 13, 2021
New lung cancer guidelines could spell a nearly 54% surge in eligibility for low-dose CT screening, with marked gains in minority populations, experts charged Tuesday in JAMA Network Open.
The influential U.S. Preventive Services Task Force just recently lowered the recommended starting age from 55 down to 50, among other changes, drawing praise from radiologists. Coupled with dropping the smoking history from 30 to 20 pack-years, Kaiser Permanente researchers believe these modifications could produce a 30% uptick in lung cancer diagnoses when compared with previous recommendations.
“While more research must be done, we know from this study we can break down existing barriers in lung cancer screening by expanding eligibility for those who fit the recommended guidelines,” lead author Debra Ritzwoller, PhD, senior investigator at the Kaiser Permanente Institute for Health Research in Colorado, said in a statement. “By screening more individuals sooner, we can potentially help catch lung cancer earlier, effectively saving more lives.”
For their study, Ritzwoller et al. analyzed data from patients who received care across five healthcare systems participating in the Population-based Research to Optimize the Screening Process Lung Consortium (PROSPR). Subjects were treated between 2010-2019, had a complete smoking history, and continuously engaged with one of the organizations for 12 or more months. Researchers compared differences in screening eligibility among this population using the broader 2021 recommendations versus the USPSTF’s previous 2013 parameters.
They found a total sample of more than 341,163 individuals ages of 50-80 who currently or previously smoked. Of those, 34,528 had electronic health records detailing their pack-year number and quit date and were eligible for screening based on 2013 guidance. However, 2021’s update increased that number by 18,533 or 53.7%. This new population included 5,833 individuals ages 50-54 (31.5%) who would have missed the cutoff. This included marked gains among women (52%), Asians/Native Hawaiians/Pacific Islanders (60.6%), Latinos (67.4%), and non-Hispanic Black individuals (69.7%).
Experts said their findings indicate that healthcare systems should plan to increase capacity by 50%-60% to help accommodate this new cohort of patients. This could include bolstering the number of trained radiologists, CT scanners, and thoracic surgeons, the authors advised.
“Improvements in uptake and adherence to annual screening also play a role in increasing this capacity,” Ritzwoller and colleagues wrote. “Screening programs will need to closely monitor capacity strain and allocate resources appropriately to meet evolving demands as the 2021 USPSTF recommendations are adopted in clinical practice.”
To read more, go to Radiology Business.
‘Seismic Shift’ Needed for Radiologists to Communicate Radiation Risks with Info-hungry Patients
By Matt O’Connor | October 13, 2021
Most patients who have undergone imaging have little understanding of their radiation dosage or associated risks, but many would like to sit down with radiologists to discuss these issues. Experts say a “seismic shift” is needed to close this communication gap.
That’s according to a new study of 2,866 patients surveyed while waiting for imaging appointments across 16 hospitals, published Wednesday in JAMA Network Open. About 44% said their knowledge of radiation is lacking, with most learning about the topic via radio and TV (27.6%) or the internet (25.3%), including Facebook and other social media outlets.
Despite this, nearly 70% want to discuss their risk with a radiologist. They also listed technologists and general providers as trusted sources.
University of California, San Francisco, experts said there is a definite role for radiologists in this regard, adding patient-centered consultations would benefit all parties.
“What is needed is a systemic and seismic shift in educating physicians and patients, in having candid conversations with patients around imaging that acknowledge the tradeoffs, and in justifying the use of all medical radiation exposure,” Carly Stewart, MHA, with the Department of Epidemiology and Biostatistics at USCF, and co-author wrote in an invited commentary. “In doing so, we improve the safety of medical imaging while reducing the physical, social, and economic toll of overuse and disease.”
The findings are based on responses gathered across teaching and nonteaching hospitals in Italy between June 2019 and May 2020. More than 98% had received at least one imaging test before, with most having involved ionizing radiation.
Of the 2,866 participants, 1,579 (55.1%) didn’t know chest CT delivers more radiation than chest X-ray, while 1,499 (52.3%) understood that nuclear exams can emit radiation. Similarly, 57% were unaware that MRI does not require ionizing radiation.
Additionally, more than half had never received radiation dose details before, during or after their imaging exam, the authors reported. Those with a higher level of education and who received info from healthcare professionals were associated with having a better grasp of radiation issues.
Luca Bastiani, PhD, with the Italian National Research Council, and co-authors, said heavy radiology workloads may contribute to communication lapses between rads and patients. But their findings make it clear something needs to be done to reach info-hungry patients.
“Several studies have highlighted patients’ preference to speak directly with imaging experts about their imaging findings, further emphasizing the need for improved direct communication between radiological staff and patients,” the authors concluded.
Read the full study in JAMA Network Open here, and the invited commentary here.
To read more, go to Health Imaging.
American College of Radiology Unveils New Imaging Appropriateness Criteria
By Marty Stempniak | October 11, 2021
The American College of Radiology unveiled new imaging appropriateness criteria covering several clinical scenarios on Monday.
ACR’s update includes five fresh topics and eight revisions to previous ones. The college first rolled out its influential criteria in 1993, offering the specialty evidence-based guidelines to aid in selecting proper imaging exams and guided procedures. It now offers 216 topics spanning 2,400 clinical scenarios.
“ACR appropriateness criteria serve a vital role in helping to ensure that patients receive the necessary, quality care that they expect from their healthcare providers,” Mark Lockhart, MD, chair of the Committee on Appropriateness Criteria, said Oct. 11. “These criteria are recognized as the national standard in radiologic care.”
New scenarios include imaging of a child with suspected Crohn’s disease, facial trauma following a primary survey, axillary masses, newly diagnosed scrotal abnormalities, and pediatric musculoskeletal infections. The guidelines offer color-coded categories of appropriateness, along with relative radiation levels for each exam.
Meanwhile, the eight updates cover everything from staging of colorectal cancer to imaging after shoulder arthroplasty. Providers can consult the materials to fulfill Protecting Access to Medicare Act requirements to consult appropriate-use criteria before ordering imaging, with the feds designating ACR as a qualified provider-led entity.
To read more, go to Radiology Business.