AHA asks Congress to Stop Looming Medicare Cuts
By Jessie Hellmann | October 6, 2021
The American Hospital Association is urging Congress to stop cuts to Medicare before they take effect next year, citing the uncertain trajectory of the COVID-19 pandemic and possible variants.
“Now is not the time for reductions in Medicare payments to providers,” Stacey Hughes, executive vice president of AHA wrote in a letter to Congressional leadership.
Without Congressional action, Medicare will face a 4% cut triggered by the COVID-19 relief bill that passed earlier this year.
Because the law raised the deficit, Medicare and other programs will be subject to spending cuts under the Pay-As-You-Go Act passed by Congress in 2010.
Congress is likely to waive PAYGO, avoiding the cuts, but will likely only do so at the last moment, putting providers on edge.
To read more, go to Modern Healthcare.
Major Insurers Running Billions of Dollars Behind on Payments to Hospitals and Doctors
By Jay Hancock | October 6, 2021
Anthem Blue Cross, the country’s second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.
Anthem, like other big insurers, is using the covid-19 crisis as cover to institute “egregious” policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. “There’s this sense of ‘Everyone’s distracted. We can get this through,’” she said.
Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.
Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they’ll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with covid surges — even after the industry has received tens of billions of dollars in emergency assistance from the federal government.
“We recognize there have been some challenges” to prompt payments caused by claims processing changes and “a new set of dynamics” amid the pandemic, Anthem spokesperson Colin Manning said in an email. “We apologize for any delays or inconvenience this may have caused.”
Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.
For all Virginia hospitals, Anthem’s late, unpaid claims amount to “hundreds of millions of dollars,” the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.
Nationwide, the payment delays “are creating an untenable situation,” the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. “Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies” needed to fight covid.
Complaints about Anthem extend “from sea to shining sea, from New Hampshire to California,” AHA CEO Rick Pollack told KHN.
To read more, go to Kaiser Health News.
Radiology Services Account for $2B of Overall Spending on Cancer Care
By Marty Stempniak | October 6, 2021
Radiology services account for nearly 20% of spending on cancer care in the U.S., one of the costliest services listed in a new study investigating medical charges in 2018.
Public health experts placed the total estimated price tag for cancer care among privately insured adults younger than 65 at a whopping $156.2 billion. Out of this figure, the group analyzed 38.4 million procedural codes totaling $10.8 billion.
Imaging exams—X-ray, CT, etc.—were responsible for $2.1 billion (19.4%) of that figure, the second most expensive category cited in the study, published Wednesday in JAMA Network Open.
Medical supplies and nonphysician services made up the highest total at $4 billion or 37%, the researchers reported. Surgery, meanwhile, contributed $1.8 billion.
“To our knowledge, this is the first characterization of service consumption and spending for privately insured adult patients younger than 65 years with cancer in the U.S.,” Nicholas G. Zaorsky, MD, MS, with Penn State Cancer Institute’s Department of Radiation Oncology, and co-authors wrote.
The researchers assessed the cost of care in 2018 for 402,115 patients with the most common types of cancer.
Breast cancer proved to be the costliest ($3.4B) and patients with this form of the disease underwent the greatest number of services (10.9 million). These individuals also incurred the highest radiology-related costs per year and received the greatest proportion of radiology services.
Lung, prostate and colorectum cancer patients also incurred higher radiology costs compared to other cancers.
At the same time, patients with colorectal cancer underwent 3.9 million services or 10.2% of the overall total, the next highest after breast cancer. Prostate cancer came in at 3.6 million (9.4%). Similarly, lung cancer accounted for $1.1 billion of overall spending while colorectal made up the same amount.
Zaorsky et al. noted their data, taken from MarketScan, mainly includes people employed by larger firms and may not accurately represent all privately insured individuals.
They will need to do more digging to determine which medical services may be needlessly pushing healthcare spending skyward.
“Further research is needed to explore the extent to which these costs reflect unnecessary or low-value care,” the team added.
Watchdog Outlines Merit-based Incentive Payment System Concerns Among Radiology and Other Specialties
By Marty Stempniak | October 6, 2021
Some providers question whether the Merit-based Incentive Payment System program is improving the quality of patient care or outcomes, according to a new watchdog report released Oct. 1.
The U.S. Government Accountability Office recently analyzed performance data from 2017- 2019 and interviewed officials from both the Centers for Medicare & Medicaid Services and 11 organizations representing MIPS-eligible specialty providers. Those included figures from diagnostic radiology along with cardiology, emergency medicine, pathology and internal medicine among others.
Eight of the 11 interviewed expressed doubts about the effectiveness of the initiative.
“Stakeholders stated that the design of the MIPS program may incentivize reporting over quality improvement, and thus, MIPS scores did not necessarily reflect the quality of care provided, but rather how well providers were complying with the reporting requirements of the program,” the report noted. “Some stakeholders said that to maximize payment adjustments, providers may choose to report on performance measures on which they are performing well or that are easy to achieve, rather than measures in areas where they may need improvement or that are clinically relevant.”
This may explain why performance scores were generally high, the GAO noted, with at least 93% earning a small positive-payment adjustment in 2017-2019. The largest landed at 1.88% while median final scores were well above the performance threshold across each of the three years. Between 72%-84% of MIPS participants earned an “exceptional” performance bonus during that span.
Congress authorized MIPS under the Medicare Access and CHIP Reauthorization Act of 2015, hoping to reward value, rather than complexity and volume of services. The system incentivizes physicians and other providers through payment adjustments based on their performance. All told, about 950,000 providers were MIPS-eligible participants in 2019, the GAO noted.
Among other concerns, 10 of the 11 stakeholders said that CMS’ feedback on providers’ scores and performance was not timely or meaningful. Some also believe certain quality measurements assess activities that are irrelevant for some specialties, and that the process for developing new metrics can be “time consuming and expensive.” Another eight stakeholders said participating in MIPS produces a low return on investment, with miniscule payment adjustments compared to the high administrative costs incurred.
On the positive side, 2 of 11 interviewees cited the MIPS low-volume threshold as a strength, reducing participation burden for smaller practices with lesser Medicare tallies. Two stakeholders also highlighted bonuses for small practices and treating complex patients, which increased scores for otherwise disadvantage providers. Three of 11 respondents commended the performance-category exemption, allowing participants to reduce excess burden.
Tens of Thousands of Radiologists and Other Docs Align in Opposing Surprise-billing Provision
By Marty Stempniak | October 5, 2021
Tens of thousands of radiologists and other medical doctors are aligning in opposition to one key provision in recently released rulemaking to ban surprise medical bills.
The Biden administration revealed its interim final rule on Thursday, outlining how the feds plan to settle payment disputes between payers and out-of-network providers. But the American College of Radiology, several other doc groups, and hospital lobbyists fiercely object to using an insurer-calculated “qualifying payment amount” as the starting point for negotiations. Generally, this would be the insurer’s median contracted rate for the same or similar service in the geographic area.
ACR has joined the American Society of Anesthesiologists, American Association of Neurological Surgeons and American Association of Orthopaedic Surgeons in fighting the regulation. Altogether, they represent more than 140,000 specialists.
“Today’s rule does not follow the congressional intent in implementing the law,” Beverly Philip, MD, a Harvard Medical School professor and president of the anesthesiology society, said in a joint statement from the four groups, issued Oct. 1. “The impact will be more record profits for insurers, who are the real winners of this rule, not patients or the physicians who have put their lives on the line throughout this pandemic.”
Congress first authorized the No Surprises Act in December as part of a year-end spending bill. ACR and others believe the new rule failed to honor lawmakers’ original aim and will lead to “drastic” payment cuts for imaging services, regardless of network status. The groups are concerned insurers will calculate these qualifying payment amounts “without meaningful oversight or transparency.” QPA also does not reflect actual payment rates, they claimed, and is “certain to be manipulated in their favor.”
Physicians, instead, want independent arbitrators to consider many factors when settling disputes, as spelled out in the original legislation. Those could include quality of outcomes, market share, patient acuity, scope of services at the facility, and prior contract history between the two parties. A bipartisan group of 97 House representatives in June urged the administration to avoid placing too much weight on any single factor (including the median network rate) in payer-provider payment negotiations, the groups noted.
Others have also come out in opposition to the interim rule. The American Medical Association highlighted its own recent study, which found that 73% of the nation’s insurer markets are “highly concentrated.” This typically results in higher premiums and narrower networks, a “root cause” of this issue, the AMA asserted.
“[The interim final rule] disregards the insurance industry’s role in creating the problem of surprise billing at the expense of independent physician practices whose ability to negotiate provider network contracts continues to erode,” President Gerald Harmon, MD, said in a statement.
The Radiology Business Management Association, Emergency Department Practice Management Association (representing ED business leaders) and Healthcare Business Management Association (revenue cycle leaders) echoed such concerns in their own joint announcement.
Meanwhile, the nation’s largest trade association for health insurance companies voiced support for the interim rule, arguing its arbitration approach will ensure businesses and families avoid unnecessary premium increases. Americas Health Insurance Plans also believes the rule will encourage more providers to join health plan networks, according to a Sept. 30 announcement.
To read more, go to Radiology Business.