April 22, 2019

CMS’ 2020 ACA Marketplace Rule Expects 70,000 Fewer Customers

CMS has released the final payment and benefit rules for the ACA Marketplaces that included a number of changes geared to move people away from the exchange plans and to attempt to lower drug prices. The final rule will allow insurers to exclude manufacturer coupons from counting towards a patient’s annual limitation on cost sharing if a medically appropriate generic drug is available. Additionally, the rule makes a technical change to how ACA subsidies are calculated, which will raise insurance costs for some customers. CMS is also finalizing its proposal to reduce the exchange fee that insurers pay by half a percentage point. That should reduce premiums slightly since insurers typically add that fee into their rates. Overall, CMS expects the changes in the final rule will result in $980 million less in federal financial assistance in 2020 and 70,000 fewer Marketplace customers. Click here for the CMS final rule, and here for the fact sheet.

  • According to the Congressional Budget Office, the number of unisured under 65 climbed from 27.5 million in 2016 to 28.9 million in 2018, click here.
  • Most Medicaid money goes to Medicaid heath plans.  In 2018, states and the federal government paid health insurance companies $307 billion to run Medicaid programs, according to the latest numbers from Health Management Associates, click here.
  • Fear of Medicare for All on Wall Street is pummeling health care stocks, at least for now.  Click here for details.  Click here for the WSJ report.

CMS Will Boost SNF Payments by 2.5%, Hospice Payments by 2.7%
CMS is proposing to raise Medicare payments for skilled nursing facilities by 2.5 percent, about $887 million, in fiscal year 2020.  CMS also estimated that a 2019 policy change to value-based purchasing would reduce aggregate payments to facilities by $213.6 million over 2020. The agency also proposed expanding data collection for quality reporting programs to all skilled nursing facility residents, regardless of their payer. Click here for details. CMS in a separate rule proposed a 2.7 percent increase in hospice payments next year, or about $540 million.  Click here for the CMS summary.

CMS Offers Payment Increases for IRFs and Inpatient Psychiatric Facilities
CMS also released a couple of proposed rules for 2020 payments for Inpatient Rehabilitation Facilities and Inpatient Psychiatric Facilities, offering both an increase in payments for 2020. For the approximately 1,600 psychiatric facilities, CMS is proposing to increase payments by an estimated 1.7 percent, or $75 million. This pays for services in psychiatric hospitals and excludes psychiatric units of an acute care hospital or critical access hospital. IRFs payments will see a proposed increase of 2.3 percent (or $195 million) for FY 2020, relative to payments in FY 2019. CMS is proposing various quality reporting requirement changes for both types of facilities as well. Click here for the IRF fact sheet, and here for the IRF rule. Click here for the psychiatric facilities fact sheet, here for the rule.

Federal Surprise Billing Legislation Would Supersede State Laws: CRS
That is according to the Congressional Research Service, the non-partisan public policy research arm of Congress. The group suggested that lawmakers should consider state laws already in place when drafting federal legislation, as well as the potential for litigation over any set payment rates. Balance billing, when an out-of-network provider bills the patient for charges that exceed her health insurance plan’s payment, is currently governed by a patchwork of federal and state laws that provide varying degrees of protection to the patients and guidance on the underlying payment question. Over the past few months several congressional committees have investigated the practice and are considering legislation to clamp down. To read the full CRS study, click here.

Senate Leader McConnell Will Move To Raise Tobacco Age to 21 when Congress Returns
Senate Majority Leader Mitch McConnell (R-KY) announced plans at a press conference to introduce legislation to raise the nationwide minimum age to buy tobacco products from 18 to 21, stating that it is his top priority this spring. Even though tobacco has long been a main export from his home state of Kentucky, McConnell said he wants to change the law to discourage vaping and teenage nicotine addiction. The legislation will be similar to the current system, where retailers have the responsibility to verify the age of anyone buying tobacco products and will follow eleven states who have already enacted laws to raise the purchasing age of tobacco products to 21. The bill will also include an exemption for members of the military. Click here for more from McConnell’s website.

  • Energy and Commerce Chairman Rep. Frank Pallone (D-NJ) and Rep. Donna Shalala (D-FL) introduced a bill last week that would allow FDA to collect user fees for e-cigarettes, raise the minimum age to purchase tobacco to 21, prohibit online sales of tobacco products, among other policies, click here.

Primary Care Accounts for Two-Percent of Medicare Spending
A new study released by the RAND Corp. found that care provided by primary care practitioners accounts for a small fraction of total spending among Medicare beneficiaries. As low as only about 2% of total Medicare spending is dedicated to primary care under a narrow definition of the term. The researchers looked at both narrow and broad definitions of the term and find that when using the broad definition the percentage went up to nearly five-percent of the annual care for Medicare beneficiaries. RAND researchers contend that the estimates are important because health system orientation toward primary care has been associated with higher quality, better outcomes and lower costs. To read the study, click here.

Washington State Likely To Be First To Create an Employee-Paid LTC Program
Washington State is poised to become the first state to establish an employee-paid program creating an insurance benefit to help offset the costs of long-term care, a step advocates say will help an aging population that is likely not prepared for the increasing costs needed for daily assistance. The measure creates a benefit for those who pay into the program, with a lifetime maximum of $36,500 per person, indexed to inflation, paid for by an employee payroll premium. It has cleared both the House and the Senate. Click here for more.

Bills Introduced that Would Exempt APMs from Stark Law Restrictions
Reps. Raul Ruiz (D-CA), Larry Bucshon (R-IN), Ron Kind (D-WI) and Kenny Marchant (R-TX) have reintroduced the Medicare Care Coordination Improvement Act of 2019 in the House shortly after Sen. Rob Portman (R-OH) and Michael Bennet (D-CO) introduced their version in the Senate. The bills would give CMS the authority to exempt alternative pay models and those under development from some Stark, or physician self-referral, law provisions by providing APMs the same waivers that accountable care organizations were granted by the ACA. Additionally, the legislation would give providers developing a new demo that CMS determines “constitutes significant progress toward establishing (an APM) model” a three-year waiver. To view the bill, click here.

Major Opioid Takedown in Appalachia Joint Task Force, Includes Dozens of Medical Professionals
The Appalachian Regional Opioid Strike Force, a coordinated effort between HHS, the Justice Department, and multiple law enforcement partners, announced last week a major takedown in the region that involved 60 charged defendants across 11 federal districts, including 31 doctors, seven pharmacists, eight nurse practitioners and seven other medical professionals, for their allegedly illegally prescribing and distributing opioids and other narcotics as well as for health care fraud schemes. The charges involve over 350,000 prescriptions and over 32 million pills distributed in West Virginia, Ohio, Kentucky, Alabama, and Tennessee to more than 24,000 patients in the region over the past 2 years. Click here for more from the Justice Department including sate-by-state figures.

This Flu Season One of the Longest
This flu season has been officially going for 21 weeks, according to reports collected through last week and released Friday by the Centers for Disease Control and Prevention. That makes it among the longest seen since the government started tracking flu season duration more than 20 years ago. Some experts likened the unusual double waves to having two different flu seasons compressed, back-to-back, into one. The previous longest recent flu season was 20 weeks, which occurred in 2014-2015. The current season began the week of Thanksgiving, a typical start time. But in mid-February, a nastier strain started causing more illnesses and driving up hospitalizations.  Still, this flu season is not nearly as bad as last winter’s 19-week season, the deadliest in at least four decades. An estimated 80,000 Americans died of flu and its complications last season. The CDC is estimating that flu-related deaths this season in the range of 35,000 to 55,000. Click here for more from the CDC.

A Light at the End of the Tunnel for Electronic Health Records
For technology more associated with physician dissatisfaction and burnout, there may be a change in the tide. Studies show that when organizations meet Stage 7 of Meaningful Use of the  HIMSS Analytics EMR Adoption Model physicians are more satisfied and have more of their clinical decisions based off of feedback from the EHR system. While varying somewhat by vendor, in 2017, 94% of U.S. hospitals used their EHR data in ways that inform clinical practice, up from 87% in 2015 and equal to 2016 usage. Conversely, patient engagement in accessing their health records electronically has been slow to catch on. However the data shows that only about 8% of patients even activate their electronic access to their records. For more information on Hospitals’ Use of Electronic Health Records Data, click here, and for how patients are utilizing electronic access to their records, click here.

CMS’ Hospital Readmissions Reduction Program Not Having Desired Impact; Rural ED Visits Jump
A new study by researchers at University of California has found that no significant differences were seen after implementation of hospital penalty payments, suggesting that any benefits of the HRRP are modest at best. The study examined U.S. and Canada hospitalization length of stay and 30-day readmission rates of patients with heart failure from 2005 through 2015 and found that a little over 18-percent of the Canadian patients were readmitted and almost 20-percent of those in the U.S. were readmitted. Canada does not have an equivalent readmission program to the U.S. Clinically, the readmitted patients from both countries bore similarities in that they had more comorbidities and hospitalizations in the prior 6 months versus patients who were not readmitted. To view the study, click here.

  • Visits to the emergency department in rural areas jumped by more than 50% since 2005 according to researchers at University of New Mexico, click here.

Global Measles Crisis Reaching Critical Numbers
Data from the World Health Organization suggests that within the first few months of 2019, 112,163 measles cases have been reported. This number is up by almost 300 percent from the same period last year. Last week, New York City declared a public health emergency due to the rapid spread of measles cases. This disease is very infectious, and in those who are non-immune, it is estimated to infect 9 out 10 people exposed to it. Anti-vaxxers are also being blamed for the surge in cases, especially impacting children who cannot be vaccinated until 12 months of age. To read the study, click here.

$350 Million in HEAL Grants Awarded to Kentucky, Massachusetts, New York and Ohio
Awarded in as part of the HEAL [Helping to End Addiction Long-term] initiative, the NIH gave Kentucky, Massachusetts, New York and Ohio $350M in an effort to support addiction prevention and treatment in primary care settings, mental health services and the criminal justice system. The grants were given with a goal to reduce opioid related heaths by 40% over the next 3 years. “We believe this effort will show truly dramatic reductions in overdose deaths are possible,” HHS Secretary Alex Azar said. To view the press release from the NIH click here.  Click here for the Wall Street Journal article.

  • The Patient-Centered Outcomes Research Institute last week announced $44.6 million to fund 12 studies looking into opioid research, how to treat pain in cancer patients, and ways to enhance prenatal care, click here.

FDA Pulls Surgical Mesh for Transvaginal Repair Off the Market
The Food and Drug Administration has ordered the manufacturers of surgical mesh products for the transvaginal repair of pelvic organ prolapse to stop selling and distributing their products in the U.S. immediately. This comes as the FDA has determined that the manufacturers, Boston Scientific and Coloplast, have not demonstrated a reasonable assurance of safety and effectiveness for the devices and have 10 days to submit their plan to withdraw these products from the market. Click here for more from the FDA.

Syphilis Becoming a Problem in Rural America
Public health officials say rural counties across the Midwest and West are showing a rapid increase in syphilis infections. While syphilis is still concentrated in major cities, it has continued spread into places like Missouri, Iowa, Kansas and Oklahoma which creates a new set of challenges as compared with urban areas, rural populations tend to have less access to public health resources, less experience with syphilis and less willingness to address. In Missouri alone, the  number of syphilis patients has more than quadrupled since 2012, going from 425 to 1,896 cases last year. Click here for more on the issue.

Pregnant Women Less Likely to Seek Treatment for Depression
That’s according to new research published in Psychiatric Services in Advance, based on a survey of 12,360 women through the National Survey on Drug Use and Health between 2011 and 2016. Researchers looked at pregnant and nonpregnant women between 18 and 44, all of whom had an episode of major depression. The study found that 51 percent of women and 43 percent of nonpregnant women did not seek help during a depressive episode. The study also found in the month before the survey was administered, 23 percent of pregnant women used alcohol and 17 percent used marijuana. To read the full study, click here.

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