March 12, 2018

March 12, 2018

Trump’s Healthcare Team Revealing Its Priorities

The President’s health care team appears to be securing its footing just months after the newest HHS Secretary took the job.  In communications over the past week, HHS Secretary Alex Azar, CMS Administrator Seema Verma, FDA Commissioner Scott Gottlieb and others have begun to detail the new direction of government when it comes to health policies and payments.  Here’s how it is shaping up:

  • In two speeches last week, Azar outlined at least four broad priorities: giving consumers more information, i.e. their own records and price transparency, different types of value-based models, and regulatory rollback. Click here for the summary in Forbes.  Click here for his speech to hospitals; click here for his AHIP speech.
  • CMS’ Innovation Center, thought to be on the endangered agency list after Trump’s election, is now thought to be evolving into a new type of health care incubator.  Click here for that report.
  • FDA’s Gottlieb told insurers last week that “money from rebates paid by sick patients who need medicine is used to subsidize everyone else” – the opposite of how insurance is supposed to work.  Click here for his speech.
  • CMS’ Verma told a health tech group last week that “CMS will be announcing a complete overhaul of the Meaningful Use program for hospitals, and the Advancing Care Information performance category of the Quality Payment Program.”  Click here for her speech.
  • CMS announced new health IT initiative – MyHealthEData Initiative – to aid providers in sharing data and ending their monopolies over patient records, click here.
  • A couple of major employer groups have launched their own initiative to influence federal health policies to drive down the cost of health care.  Known as DRIVE, the initiative seems to be influencing this Administration. Click here for more.

Senators Say Anthem’s New ER Payment Denials May Be Illegal

U.S. Senators Ben Cardin (D-MD) and Claire McCaskill (D-MO) are calling on HHS and the Labor Department to review a pattern of actions by Anthem health care, a BlueCross BlueShield affiliate, which may have violated consumers’ rights. In a joint letter, the senators outline how Anthem may have violated federal law by disapproving emergency room claims that should have been allowed under the Prudent Layperson standard, which is applicable in group health plans, plans offered on the individual and group markets, Medicare, and Medicaid managed care plans. Click here for the letter.

  • Click here for the March 2, 2018 Anthem and AMA press release where they agree to “streamline and/or eliminate low-value prior-authorization requirements.”
  • Click here for the March 5, 2018 hospital associations’ joint letter to Anthem asking it to retract the emergency department and imaging policies.

UnitedHealthcare May Follow Similar Path as Anthem on ED Claims

Beginning March 1, 2018 UnitedHealthcare will review and potentially adjust or deny ED claims with Level 4 (99284, G0383) and Level 5 (99285, G0384) E/M codes. Click here for the policy approved 9/13/17 and revised 3/1/2018; click here for the UHC Provider Alert and here for a good summary from the media.  UnitedHealthcare is using its Optum Emergency Department Claim Analyzer tool to review the claims. Certain criteria may exclude claims from being subject to an adjustment or denial:

  • Patient is admitted to inpatient, observation or has outpatient surgery during ED visit;
  • Critical care patients or patients under 2 years old;
  • Claims with certain diagnoses that most often necessitate greater than average resource usage;
  • Patients who expire in the ED;
  • Claims that don’t disparately deviate from the Analyzer tool.

Hospitals, Pharmacies, Insurers Join To Push Generic Drug Bill

The American Hospital Association has joined the Campaign for Sustainable Rx Pricing, which is launching a six-figure ad campaign to push for the CREATES Act (S. 974), a bill designed to speed generic drugs to market.  The diverse coalition – which includes Anthem, CVS and Walmart – is pushing to include the bill in this month’s omnibus legislation, citing CBO estimates that it would save the government $3.8 billion over 10 years. Click here to see the 30-second ad.

Senate Committee to Hold 340B Hearing 

The Senate Health Committee has set a hearing for this Thursday (March 15th) at 10:00 am ET to discuss the 340B Drug Program. Witnesses are yet to be announced and the only indication of what will be discussed is in the title of the hearing, “Perspectives on the 340B Drug Discount Program.” The Committee did reach out in the weeks leading to the announcement to various stakeholders requesting information on how they implement and utilize the program. Click here for the hearing website.

  • A federal appellate court scheduled arguments for May 4 in the hospital lawsuit against CMS’ 340B payment cut.

CMS Issues Updated CJR Answers, Raising More Questions

CMS’ decision not to answer a question about how hospitals will be paid going forward under the Comprehensive Care for Joint Replacement (CJR) model is sparking providers’ fears of financial instability. Last week, CMS posted a 58-page frequently asked questions document, and one of the most pressing inquiries was how payment under the CJR model would change going forward now that the agency has finalized a rule that removed total knee arthroscopy from the list of procedures that can only be performed in inpatient facilities.  Click here for the updated FAQ document. The total number of participating hospitals as of February 1, 2018 is 465; 390 of these 465 hospitals are located in the 34 mandatory MSAs (10 of these 390 are rural and 1 is low volume; all 11 opted into continue participation in CJR) while 75 of these 465 providers are located in the voluntary MSAs. The list of CJR participant hospitals is available here.

  • Click here for a JAMA report on the characteristics of those making money in CJR.

Arkansas Third State to Win Approval for Work Requirements

The state of Arkansas became the third state to receive permission to require certain Medicaid enrollees work in order to keep their health coverage. However, CMS rejected the state’s proposal to cap the eligibility for Medicaid expansion at the federal poverty line and reducing the roll by about 60,000. Under the waiver that was approved last week, low-income adults between the ages of 19 and 49 will be required to work or participate in other job-related activities for at least 80 hours per month and any individual who fails to comply for a three-month period will lose their benefits until the following year. To read the approval letter that includes the scope of Arkansas’ program, click here.

  • Amazon is offering a discount on Prime membership for Medicaid recipients, click here.

Cigna to Buy Express Scripts for $67 Billion

The health insurance giant Cigna announced last week that it will pay about $67 billion to buy pharmacy benefits manager Express Scripts. The two companies say in a joint statement that the merger would “the best care to patients, and the most value to clients.”  This merger is just the latest example of health care titans attempting to come together across the industry. In December, the national pharmaceutical chain CVS agreed to buy Aetna for $69 billion – a deal that is still being reviewed by federal antitrust regulators. This potential deal comes after Cigna’s attempted purchase of Anthem was blocked by federal courts last year. Click here to read the announcement.

Opioid Crisis is Worsening: CDC

The CDC says that new emergency room data shows a sharp uptick in opioid overdoses across the country. Hospitalizations for opioid overdoses are up 30 percent in states hit hardest by drug abuse and Midwestern states saw a 70 percent uptick in opioid overdoses. The latest CDC Vital Signs report reviewed emergency room data in 45 states and found a significant uptick in hospitalizations for overdoses across the country between July 2016 through September 2017. Click here for the report.

  • New study in JAMA found that “the use of opioid vs nonopioid medication therapy did not result in significantly better pain-related function,” click here.
  • Governors emphasized the need for additional federal funding and flexibility in the fight against the opioid crisis in Senate Health Committee hearing, click here.
  • The House Energy & Commerce Health Subcommittee announced a two-day legislative hearing on March 21 and 22 to examine more than 20 bills to combat the opioid crisis, click here.
  • Florida can force people with an opioid addiction into treatment.  Will other states follow suit?  Click here.

Number of Male Gynecologists Dropping, Debate Ensues In 1970, 7% of gynecologists were women. Now 59% are. Some men fear the falling number of male OB-GYNs could eventually lead to them being excluded from the specialty. They believe this is not only unfair, but also has subtle ramifications that go beyond patients’ comfort on the examination table. The debate about male OB-GYNs taking place in universities and doctors’ offices across the country has stoked concern and resentment among men and women, creating the ultimate collision of medicine and gender politics. Click here for the story.

“Critical Deficiencies” Found at VA Medical Center in Nation’s Capitol

The Department of Veterans Affairs Office of Inspector General released a report last week finding that the VA Medical Center in Washington, D.C. “has for many years suffered a series of systemic and programmatic failures that made it challenging for healthcare providers to consistently deliver timely and quality patient care.” Click here for the full report.

CMS Says NO to Idaho

The Trump administration issued a written warning to Idaho last week that a maneuver by the state to allow health plans that fall outside the Affordable Care Act’s insurance rules “may not be substantially enforcing” the law. The warning, in a letter to Idaho’s governor and insurance director by CMS, does not immediately block the state’s unique decision to encourage insurers to sell health coverage lacking some benefits required by the law, such as maternity care or certain coverage of preexisting conditions. The letter is a strong signal, however, that HHS is unwilling to allow Idaho to move forward on its own. Click here for more.

ACA Premiums Could Rise as Much as 90 Percent in Some States

Health insurance premiums in the Affordable Care Act’s individual markets will increase a cumulative 35-90 percent, depending on the state, over the next three years if current policies are left in place, says the findings of a new report. An interactive map created by the research allows users to drill down on data used in the analysis from Covered California’s March 2018 brief. The analysis projected that there will be “catastrophic” premium increases of more than 90 percent in 17 states  by 2021 and nineteen states will face 50 percent hikes, with others receiving increases of up to 35 percent. To view the map and accompanying data, click here.

Report Establishes Measures for Rural Hospital and Ambulatory Settings The Quality Forum released the first of three reports detailing a core set of quality measures most relevant for rural hospital and ambulatory settings. The report establishes that the core measures the group will identify should be NQF-endorsed, cross-cutting, resistant to low case-volume, and also address transitions in care. The report also expressed interest in measures which would address health issues relevant to rural populations such as mental health, substance abuse, and perinatal conditions. Click here to read the report.

  • The CAH Coalition is actively working with Congress and federal agencies to best support the unique needs of Critical Access Hospitals. Click here to learn more about their work.

Cost of Blood Pressure Control Growing

The spending growth in hypertension, one of the most common chronic conditions in the United States grew more than 18 percent between 2012 and 2016, according to a new study of private health plans by the Health Care Cost Institute. The spending growth on adults with the condition was driven mostly by brand-name prescription drugs, despite more lower-cost generics being issued. The report also found that hypertensive adults accounted for 41 percent of all health spending in 2016, despite making up 18 percent of the population studied by HCCI. To read the report, click here.

HHS Inspector General Finds Vulnerabilities in Home Health Surveys

A recently released HHS OIG report states that reliance on unverified patient lists creates a weakness in home health surveys, which makes the program area susceptible to fraud, waste, and abuse. Medicare requires home health agencies (HHAs) to undergo onsite surveys conducted by State survey agencies or accrediting organizations prior to initial enrollment and at least once every 36 months thereafter, to ensure that they comply with Medicare standards. The OIG found that as part of this process surveyors use HHA supplied lists to select patients for review, prompting concern that HHAs could manipulate these lists to avoid scrutiny of certain patients. Click here for the report.

Higher Levels of Vitamin D Lowers Risk of Cardiovascular Disease: Study In the Norwegian study, researchers investigated levels of vitamin D in the development of cardiovascular disease among older individuals. Researchers assessed blood samples from 4,114 adults who had suspected angina pectoris, which is chest pain as a result of coronary heart disease. Subjects were an average age of 62 at study baseline, and they were followed-up for an average of 12 years. The results found that participants with the optimal vitamin D concentrations were 30 percent less likely to die of cardiovascular disease. Click here for the study.

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