News Clips
Colorado Sun: Opinion: There is no good reason why a visit to the doctor should cost triple in a hospital (9/26) – Everyone can agree that patients shouldn’t be charged two or three times more for the same health services at the same location, just because it’s under hospital ownership. It’s a bipartisan issue of fairness: patients shouldn’t be charged more for the same care just because of where they receive it. Let’s call on our leaders to put patients ahead of large hospital profits. By passing common sense solutions such as the Lower Costs, More Transparency Act, Congress can save patients billions of dollars and make our system more fair.
Politico: McMorris Rodgers doubles down on transparency bill (9/25) – House Energy and Commerce Chair Rodgers (R-WA) acknowledged that things are very “fluid” with the PATIENT Act, which would lower Medicare payments to off-campus hospital outpatient clinics for Medicare drug reimbursements. A vote on the bill was scuttled earlier this week amid chaos on Capitol Hill surrounding how to fund the federal government. Rodgers hinted that this legislation, which includes measures on price transparency, is only the first step in Congress’ work on tackling health care consolidation and costs. “We need to address what is driving the cost of health care,” she said. “We have seen a lot of consolidation; it’s not bringing down the cost of health care.”
Healthcare Dive: The one code Congress must support: G2211 (9/22) – The problem is our system is set up to provide sick care, not healthcare. Decades of underinvestment have resulted in a system with too few primary care physicians, shorter patient visits and long appointment wait times. However, the tide is beginning to turn. One physician billing code — set to go into full effect next year — is designed to compensate for the complex, high-value visits primary care physicians provide as part of a longitudinal relationship with a patient. Medicare pays for physician services based on the cost of providing those services — everything from the physician’s time to the crunchy paper you sit atop on the exam table. The physician billing code known as G2211 allows physicians to capture the full scope of their visits with their patients. It is a direct investment in the evidence-based, whole-person primary care that patients need.
Health Affairs: The Missing Piece In Health Care Transparency: Ownership Transparency (9/22) – Health care transparency is one of those rare policies with bipartisan support. On September 7, GOP House leaders released a bill, the Lower Costs, More Transparency Act, to improve the transparency of health care prices, bills, and the practices of pharmacy benefit managers (PBMs). Although all the proposals purport to increase transparency in health care, they do so in different ways and to different extents. Notably, the Lower Costs, More Transparency Act is missing a key form of transparency: transparency in the ownership of health care providers. Lack of ownership transparency allows health care consolidation to intensify unchecked, with corresponding increases in prices. Similarly, location transparency measures without ownership transparency will limit progress toward site-neutral payment reform.
STAT: FTC sues private equity firm Welsh Carson, U.S. Anesthesia Partners for allegedly creating a monopoly (9/21) – The Federal Trade Commission has sued U.S. Anesthesia Partners and its private equity owner, alleging in federal court the two partners formed a monopoly in order to drive up prices and boost their profits. This lawsuit is novel by also going after a private equity sponsor that it believes hatched the entire alleged scheme — and could serve as a warning to other private equity deals, which have flooded the health care industry. The FTC has made it clear under new proposed merger guidelines that antitrust regulators will scrutinize and challenge these types of roll-up acquisitions by private equity firms if they create an overly concentrated market. Experts said there are many other examples of highly consolidated physician markets, spurred by private equity firms, that now could catch the FTC’s attention.
NEJM: The Case for Administrative Benchmarks (and Some Challenges) (9/20) – An example of the administrative benchmark approach is the Accountable Care Prospective Trend component of the benchmarks for ACOs in the Medicare Shared Savings Program, which uses an initial benchmark, based on baseline spending, that grows based on spending growth that was forecast when the program was launched rather than realized spending growth. This administrative benchmark allows benchmark growth to diverge from, rather than track with, realized spending growth, which avoids shortcomings of empirical benchmarks and allows for greater incentives to deliver care efficiently, providing predictability over time. The key to success for administrative benchmarks is that the administrative growth rate needs to be set low enough so that Medicare saves money relative to what would happen without ACOs or MA, but high enough to still encourage participation.
Modern Healthcare: Providers concerned about Medicare physician pay cut proposal (9/18) – Providers want CMS to reconsider cutting physician pay and avoid financial repercussions that could force them to scale back care. Providers that commented on the draft regulation were generally supportive of CMS' proposals for MSSP ACOs. NAACOS was mostly pleased with proposed changes to the Medicare Shared Savings Program. “We are especially gratified by your proposals to cap the regional risk score, use the same risk model in the benchmark and performance years, and offer a new quality reporting option for ACOs. Many of these policies are responsive to concerns and suggestions raised by our members,” NAACOS wrote. Still, NAACOS wants CMS to reconsider plans that it argues could increase clinician burden, including electronic quality reporting and beneficiary notifications, and to support inclusion of all providers in the model.
Axios: Fight over Medicare pay hinges on primary care (9/18) – A Medicare effort to boost payments to primary care doctors and better coordinate care for patients with complex medical needs has set off a lobbying frenzy to forestall steep cuts specialists would face as a result. In 2020, CMS created a new Medicare billing code, known as G2211, that would better reimburse physicians for complex patient office visits. Congress quickly stepped in amid concern from specialist groups and delayed the code's implementation until Jan. 1, 2024. Physicians are lobbying Congress to change their payment system so increases to one specialty's payment don't have to mean decreases to another's. Lawmakers have had early discussions about it, but doctors don't expect to see big changes this year. "While we would love most of our members to be getting the benefit of this code, the reality is, when new codes are introduced, utilization is usually pretty low," said Stephanie Quinn, AAFP.
Healthcare Dive: CMMI teases new behavioral, maternal health models launching this year (9/15) – The CMS Innovation Center (CMMI) hopes to announce two new models in behavioral health and maternal health later this year, according to Liz Fowler, director of CMMI. Both upcoming models have “a heavy role” for the Medicaid program, Fowler said Thursday during a Health Affairs policy briefing. The behavioral health model, which is currently going through clearance, will also involve Medicare. CMMI is also working on strategies to better integrate specialty care with primary care, a priority Fowler called “a hard nut to crack.” CMMI is also continuing to develop initiatives to bring value-based payments to specialty care. The agency recently extended a bundled payments model for care episodes for another two years, and earlier this summer issued a request for information about future episodic models.
Healthcare Innovation: Can the New “AHEAD” Model Attract State and Provider Participation? (9/15) – Will state governments, hospitals, and medical groups really join the new AHEAD Model in large enough numbers to make it successful? In an article published online on Sep. 14 in the Forefront (op-ed) section of Health Affairs entitled “Three Outstanding Questions About CMS’s Ambitious New AHEAD Model,” Troyen A. Brennan, M.D., M.P.H., writes that he has some questions. The fundamental challenge for “AHEAD,” is the question of whether private insurers and hospitals will participate in it. Per that, he says, private insurers and hospitals are only going to get on board if state governments are prepared to push hard to make the AHEAD model work. But how many have that drive and commitment and can reasonably sustain it over a ten year period? Some states will take up the challenge and we will learn new things about improving care, addressing equity, and controlling costs -- all of which will lead to a better health care system. But a lot of challenges will have to be overcome, and our current experience with these kinds of reforms does not provide anywhere near all the answers.
Health Affairs: Can the New “AHEAD” Model Attract State and Provider Participation? (9/14) –CMS in early September announced one of its most ambitious and wide-ranging demonstration projects, the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. The AHEAD Model is ambitious indeed. But CMS implies that is the next step in an ongoing evolution from three successful programs already implemented: the Maryland Total Cost of Care Model, the Vermont All Payer ACO Model, and the Pennsylvania Rural Health Model. Each of these have components that have been incorporated into the AHEAD Model, giving CMS some confidence that its expectations are not outlandish and that states will participate. Yet none of the three are an exact fit, and their respective histories do raise some questions. This brief review of the “prototype all payer/total cost of care” models then prompts three big questions about the AHEAD model. They center on the three key constituencies: private insurers, hospitals and state governments. For each, the question is similar: will they participate?
Medical Economics: Enhanced primary care: a solution to the nation’s skyrocketing health care costs? (9/15) – Despite its perceived value, the supply of primary care providers is dwindling, particularly in rural areas, in part due to decades of underinvestment and perverse incentives inherent in our fee-for-services system, which rewards volume over value. Part of the underinvestment is driven by low reimbursement for primary care that may undervalue the time and resources that primary care clinicians need to best serve their patients. Changing how we pay for primary care is a key part of the solution. Perhaps the secret to reducing costs is actually paying for more care – not less – but making sure it’s the right kind of care. As evidenced by increasing adoption and investment in all-inclusive, round-the-clock primary care models, investing heavily in lower-cost, higher-value care (like preventive care) up front can result in meaningful savings down the road. It also requires a fundamental rethinking of what primary care is.
Axios: New data shows price hikes for common medical procedures (9/14) – Colonoscopies can cost up to nearly 60 percent more when performed in a hospital compared to an ambulatory surgery center, according to a new analysis from a Blue Cross Blue Shield Association subsidiary. The report draws on claims data for 133 million Blues members from 2017 through 2022 and underscores insurers' arguments for site-neutral policies that pay the same for some services, regardless of the setting. Paying more for services that can be delivered in a less-intensive setting could result in higher insurance premiums and more out-of-pocket costs for consumers. The allowed cost, or the negotiated price, for a routine colonoscopy screening was $1,124 on average in hospital outpatient departments, 32 percent higher than the $925 allowed in ambulatory surgery centers last year.
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