<?xml version="1.0" encoding="UTF-8"?><rss version="2.0" xmlns:content="http://purl.org/rss/1.0/modules/content/" xmlns:wfw="http://wellformedweb.org/CommentAPI/" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:atom="http://www.w3.org/2005/Atom" xmlns:sy="http://purl.org/rss/1.0/modules/syndication/" xmlns:slash="http://purl.org/rss/1.0/modules/slash/" > <channel> <title>Affordable Care Act – Policy & Medicine</title> <atom:link href="https://www.policymed.com/category/affordable-care-act/feed" rel="self" type="application/rss+xml" /> <link>https://www.policymed.com</link> <description>Legal, Regulatory, and Compliance Issues</description> <lastBuildDate>Mon, 09 Sep 2024 00:44:05 +0000</lastBuildDate> <language>en-US</language> <sy:updatePeriod> hourly </sy:updatePeriod> <sy:updateFrequency> 1 </sy:updateFrequency> <image> <url>https://www.policymed.com/wp-content/uploads/2018/05/cropped-favicon-32x32.png</url> <title>Affordable Care Act – Policy & Medicine</title> <link>https://www.policymed.com</link> <width>32</width> <height>32</height> </image> <item> <title>CMS Issues Enforcement Report on NSA and ACA</title> <link>https://www.policymed.com/2024/10/cms-issues-enforcement-report-on-nsa-and-aca.html</link> <comments>https://www.policymed.com/2024/10/cms-issues-enforcement-report-on-nsa-and-aca.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Fri, 04 Oct 2024 08:43:13 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[CMS]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=17110</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" fetchpriority="high" srcset="https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658.jpg 1200w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-450x300.jpg 450w" sizes="(max-width: 1200px) 100vw, 1200px" /></div>The United States Centers for Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight recently issued a report on health insurance market reforms, including the Affordable Care Act (ACA) and the No Surprises Act (NSA). According to the report, as of June 30, 2024, CMS received more than 16,000 complaints under its […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" srcset="https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658.jpg 1200w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2024/06/stencil.default-2024-06-23T134226.658-450x300.jpg 450w" sizes="(max-width: 1200px) 100vw, 1200px" /></div><p>The United States Centers for Medicare and Medicaid Services (CMS) Center for Consumer Information and Insurance Oversight <a href="https://www.cms.gov/files/document/august-2024-complaint-data-and-enforcement-report.pdf">recently issued a report</a> on health insurance market reforms, including the Affordable Care Act (ACA) and the No Surprises Act (NSA). According to the report, as of June 30, 2024, CMS received more than 16,000 complaints under its jurisdiction related to Title XXVII of the Public Health Service (PHS) Act, most of which are related to alleged violations of NSA requirements. The report also indicates the number of complaints not under CMS’ jurisdiction but that were subsequently referred to the appropriate entity (without information regarding the resolution).</p> <p>The Center for Consumer Information and Insurance Oversight within CMS is responsible for implementing many aspects of the ACA, including provisions related to private health insurance. Under the No Surprises Act, as of January 1, 2022, consumers have new protections when receiving emergency care, non-emergency care from out-of-network providers at in-network facilities, and air ambulance services from out-of-network providers. Under the NSA, excessive out-of-pocket costs are restricted and emergency services must be covered by insurance without prior authorization, irrespective of whether a provider or facility is in-network.</p> <p>To compile the report, CMS considered “complaints” all information received regarding potential federal law violations, including information from stakeholder feedback, referrals from Congress, referrals from individual states or territories, No Surprises Help Desk complaints, and news articles.</p> <p>The total number of complaints received was 16,073, with 3,373 of those remaining open at the time of the report. Of the 12,700 complaints closed, 4,438 were closed with no violation found and 400 were closed with a violation found. CMS notes that CMS has directed various plans, issuers, providers, health care facilities, and providers of air ambulance services to take action to address instances of non-compliance, resulting in roughly $4,183,383 in monetary relief paid to consumers or providers.</p> <p>The three most common complaints against non-federal government plans and insurers were: non-compliance with qualifying patient amount (QPA) requirements (1,035 complaints); late payment after independent dispute resolution (IDR) determination (675 complaints); and non-compliance with 30-day initial payment or notice of denial of payment requirements (390 complaints).</p> <p>The three most common complaints against providers, facilities, and providers of air ambulance services were: surprise billing for non-emergency services at an in-network facility (4,286 complaints); surprise billing for emergency services (2,577 complaints); and good-faith estimate (1,922 complaints).</p> <p>Importantly, because CMS does not disclose information about ongoing investigations, the data within the report is limited to complaints that are closed by CMS.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2024/10/cms-issues-enforcement-report-on-nsa-and-aca.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>ACA Section 1557: A Comprehensive Overview for Healthcare Providers</title> <link>https://www.policymed.com/2024/07/aca-section-1557-a-comprehensive-overview-for-healthcare-providers.html</link> <comments>https://www.policymed.com/2024/07/aca-section-1557-a-comprehensive-overview-for-healthcare-providers.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Wed, 10 Jul 2024 08:22:49 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Guidelines]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=16962</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" srcset="https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96.jpg 1200w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-450x300.jpg 450w" sizes="(max-width: 1200px) 100vw, 1200px" /></div>On a recent evening, the Medical Society of New Jersey and Policymed.com hosted a pivotal webinar to discuss the 2024 final rule for ACA Section 1557. This regulation, which came into effect on July 5, 2024, addresses non-discrimination in healthcare and poses significant implications for healthcare providers. The webinar was hosted by David Swee, MD, […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96.jpg 1200w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2023/05/stencil.default-96-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div><p>On a recent evening, the Medical Society of New Jersey and Policymed.com hosted a <a href="https://www.youtube.com/watch?v=nA6tuWDGk7Q">pivotal webinar</a> to discuss the 2024 final rule for <a href="https://www.policymed.com/2024/06/summary-of-section-1557-of-the-affordable-care-act-and-application-for-health-systems-medical-practices-and-clinical-research.html">ACA Section 1557</a>. This regulation, which came into effect on July 5, 2024, addresses non-discrimination in healthcare and poses significant implications for healthcare providers. The webinar was hosted by <a href="https://msnj.org/news/670778/David-E.-Swee-MD-Installed-as-232nd-President-of-the-Medical-Society-of-New-Jersey.htm"><strong>David Swee, MD</strong></a><strong>,</strong> President of Medical Society of New Jersey, and featured prominent speakers, including <a href="https://www.policymed.com/author/admin"><strong>Thomas Sullivan</strong></a>, Senior Vice President at Clinical Education Alliance; <a href="https://www.bakerdonelson.com/stefanie-j-doyle"><strong>Stefanie Doyle</strong>,</a> an associate at Baker Donelson; and <a href="https://www.bakerdonelson.com/alexandra-p-moylan"><strong>Alexandra P. Moylan</strong></a>, a shareholder at Baker Donelson.</p> <p><strong>Understanding the 2024 Final Rule</strong></p> <p>Stefanie Doyle began the presentation by outlining the history and evolution of ACA Section 1557. The 2024 final rule builds upon previous regulations from 2016 and 2020, introducing several key changes:</p> <ol> <li><strong>Expanded Definition of Sex Discrimination</strong>: The rule now explicitly prohibits discrimination based on gender identity and sexual orientation. It mandates that healthcare providers cannot impose restrictions on care based on a patient’s gender identity or sex assigned at birth.</li> <li><strong>Inclusion of Medicare Part B Providers</strong>: For the first time, the rule includes Medicare Part B recipients as covered entities, expanding the scope of the regulation significantly.</li> <li><strong>Affirmative Actions Required</strong>: Providers must take proactive steps to inform patients of their rights and protect them from discrimination. This includes expanding assistance for individuals with limited English proficiency and disabilities.</li> <li><strong>Non-Discrimination in Telehealth</strong>: The rule emphasizes that telehealth services must be provided without discrimination, ensuring that individuals with disabilities have equal access to these services.</li> </ol> <p><strong>Compliance and Enforcement</strong></p> <p>Ms. Doyle explained that the Department of Health and Human Services (HHS) Office for Civil Rights (OCR) will enforce the rule. If a violation is found, OCR will first seek voluntary corrective action from the provider, which may include revising policies and procedures and/or implementing training and monitoring programs. If a covered entity refuses to take corrective action, non-compliance can result in the suspension or termination of federal financial assistance, or in a referral to the Department of Justice for enforcement proceedings. Additionally, the rule supports a private right of action, allowing individuals to sue providers for non-compliance.</p> <p><strong>Specific Requirements for Providers</strong></p> <p>All providers, regardless of size, must develop and implement written policies to facilitate compliance, including non-discrimination policies, language access procedures, and procedures for providing auxiliary aids and services.</p> <p>Providers with more than 15 employees must designate a Section 1557 Coordinator who is responsible for ensuring compliance with the rule. The coordinator will handle grievances, coordinate training, and oversee the implementation of policies and procedures.</p> <p><strong>Language Access</strong>: Providers must ensure meaningful access to services for individuals with limited English proficiency. This involves providing qualified interpreters and translators and ensuring that critical documents are accurately translated.</p> <p><strong>Training</strong>: Relevant employees, including those in patient care, financial services, and executive leadership, must be trained on the new civil rights policies and procedures. This training must be completed within 300 days of the rule’s effective date (May 1, 2025).</p> <p><strong>Addressing Discrimination in Clinical Decision Support Tools</strong></p> <p>Alexandra Moylan highlighted the importance of addressing potential biases in clinical decision support tools, including AI and machine learning systems. Providers must ensure that these tools do not incorporate discriminatory practices based on race, gender, or other protected characteristics. Efforts should be made to identify and mitigate biases, to ensure fair and equitable treatment for all patients.</p> <p><strong>Q&A Session Highlights</strong></p> <p>During the Q&A session, several critical points were addressed, including:</p> <ul> <li><strong>Translation Services</strong>: Providers must offer free translation services to all patients, not just those covered by Medicare. This requirement aims to ensure that language barriers do not impede access to healthcare.</li> <li><strong>Training and Compliance</strong>: Smaller practices must also comply with the rule, and the required training should cover all relevant employees, including those in non-patient-facing roles.</li> <li><strong>Implementation Challenges</strong>: Webinar participants raised concerns about the practical challenges of implementing these requirements, especially for smaller practices and those serving diverse communities. The speakers emphasized the importance of leveraging resources from professional organizations and pooling resources where possible.</li> </ul> <p><strong>Conclusion</strong></p> <p>The 2024 final rule for ACA Section 1557 represents a significant step forward in promoting non-discrimination in healthcare. While the new requirements pose challenges for healthcare providers, they also offer an opportunity to improve access and equity in healthcare services. The Medical Society of New Jersey’s webinar provided valuable insights and practical guidance for navigating these changes, emphasizing the importance of proactive compliance and patient-centered care.</p> <p>For more detailed information and resources, healthcare providers can visit Policy and Medicine, where this article and the webinar recording will be available. As the healthcare landscape continues to evolve, staying informed and prepared will be crucial for ensuring compliance and providing high-quality care to all patients.</p> <p><strong>Additional Resources and Upcoming Training</strong></p> <p><strong>Thomas Sullivan</strong> concluded the webinar by directing attendees to additional resources available on <a href="https://www.policymed.com/2024/06/summary-of-section-1557-of-the-affordable-care-act-and-application-for-health-systems-medical-practices-and-clinical-research.html">Policy and Medicine</a>. These include comprehensive articles, updates on regulatory changes, and links to further reading on ACA Section 1557.</p> <p>Moreover, the Medical Society of New Jersey, in collaboration with the Clinical Education Alliance, is offering an upcoming course on the ACA 1557 new requirements and <a href="https://clinicaloptions.com/content/dea-resource-center">courses for DEA licensure</a>, which includes eight hours of substance use disorder and opioid management training. This course, along with <a href="https://clinicaloptions.com/content/state-required-cme/new-jersey">New Jersey state required courses</a> on controlled substances, aims to help healthcare providers meet their continuing education requirements and stay compliant with the latest regulations.</p> <p>For more information on these courses and to access the <a href="https://www.youtube.com/watch?v=nA6tuWDGk7Q">webinar recording</a>, <a href="https://www.policymed.com/wp-content/uploads/2040/12/ACA-1557-Webinar-6-27-2024-MSNJ-Final.pdf">slides</a> and <a href="https://www.policymed.com/2024/06/summary-of-section-1557-of-the-affordable-care-act-and-application-for-health-systems-medical-practices-and-clinical-research.html">related articles</a>, visit Policy and Medicine. The Medical Society of New Jersey is committed to supporting healthcare providers through these regulatory changes and ensuring that all patients receive equitable, high-quality care. Clinical Care options is preparing courses to help healthsystems and healthcare providers training for updates and more information, please send an email to tsullivan@clinicaloptions.com</p> <p><a href="https://www.youtube.com/watch?v=nA6tuWDGk7Q">Webinar Recording</a></p> <p><a href="https://www.policymed.com/wp-content/uploads/2040/12/ACA-1557-Webinar-6-27-2024-MSNJ-Final.pdf">Slides from Webinar</a></p> <p><a href="https://www.policymed.com/2024/06/summary-of-section-1557-of-the-affordable-care-act-and-application-for-health-systems-medical-practices-and-clinical-research.html">Related Articles</a></p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2024/07/aca-section-1557-a-comprehensive-overview-for-healthcare-providers.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>Risk Adjustment Payment Program in the ACA Seems to Be Working</title> <link>https://www.policymed.com/2024/02/risk-adjustment-payment-program-in-the-aca-seems-to-be-working.html</link> <comments>https://www.policymed.com/2024/02/risk-adjustment-payment-program-in-the-aca-seems-to-be-working.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Tue, 20 Feb 2024 09:31:53 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=16639</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82.jpg 1200w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div>A recent analysis conducted by Oliver Wyman Actuarial and backed by the Blue Cross Blue Shield Association, found that overall, according to publicly available data, the Affordable Care Act risk adjustment program is working, with funds largely moving from payers with low claims to those with high claims. The goal of the risk adjustment program […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82.jpg 1200w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2023/02/stencil.default-82-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div><p>A <a href="https://www.oliverwyman.com/our-expertise/insights/2023/nov/aca-risk-adjustment-success-story-with-room-to-improve.html">recent analysis</a> conducted by Oliver Wyman Actuarial and backed by the Blue Cross Blue Shield Association, found that overall, according to publicly available data, the Affordable Care Act risk adjustment program is working, with funds largely moving from payers with low claims to those with high claims.</p> <p>The goal of the risk adjustment program was to make it easier for insurers to participate in ACA exchanges by distributing funds from payers that cover fewer high-cost enrollees to those that cover more high-cost patients. This program was implemented to help achieve one of the goals of the ACA: to prevent insurers from using adverse selection and refusing to cover people with high health care needs and costs and to make it so insurers were competing based on the cost and quality of the insurance policies they offer, not their ability to avoid high-cost individuals.</p> <p>The authors of the analysis compared each issuer’s risk adjustment transfer amount to its average claim level, relative to other issuers in the state. They then fit a line to the data to see the correlation between risk adjustment and claim levels, finding that as noted above, the risk adjustment system is moving funds from those issuers with relatively low claims to those issuers with relatively high claims, as intended.</p> <p>The analysis further found that 65% of smaller insurance companies received risk adjustment payments in 2021. While there did not seem to be evidence that smaller payers are disadvantaged in the program, they did tend to see more variance in their payouts per member per month, when compared to the larger payers.</p> <p>Additionally, while smaller payers did not seem to be disadvantaged, the report found that plans that enroll large numbers of people with high care costs tend to be underpaid through risk adjustment as the program underpays for high-cost claimants. “We believe the data presented here shows that neither small, nor new issuers are being disadvantaged by the risk adjustment system,” the researchers wrote. “We also believe that the data presented here shows that plans enrolling a disproportionate share of high-cost enrollees are generally disadvantaged.”</p> <p>The data also indicated that issuers that are new to either the individual ACA market or a particular state were not disadvantaged in the program.</p> <p>The report concluded that some insurance companies’ financial difficulties stemming from the ACA market may not be the risk adjustment program, but the result of underpricing. The authors recommend that issuers that participate in the individual ACA market anticipate the impact of risk adjustment in their premiums and issuers who will be payers need to include an adequate provision in their premiums to make those payments while issuers that will be receiving risk adjustment payments need to reflect those payments and lower their premiums, so they can bring competitive premiums to the market.</p> <p>The authors of the report therefore believe that lawmakers may not want to first consider making changes to the risk adjustment system to specifically favor new or smaller issuers, but may want to review other potential factors and reasons for certain issuers’ financial difficulties. Additionally, the study authors raise concerns that changes to the risk adjustment system may inadvertently cause existing issuers to reconsider their participation in the market.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2024/02/risk-adjustment-payment-program-in-the-aca-seems-to-be-working.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>Insurance Medical Loss Ratio Mandate Effect on Healthcare Innovation</title> <link>https://www.policymed.com/2023/10/insurance-medical-loss-ratio-mandate-effect-on-healthcare-innovation.html</link> <comments>https://www.policymed.com/2023/10/insurance-medical-loss-ratio-mandate-effect-on-healthcare-innovation.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Fri, 13 Oct 2023 08:12:36 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Insurance]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=16452</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="343" height="147" src="https://www.policymed.com/wp-content/uploads/2023/10/Medical-loss-ratio.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2023/10/Medical-loss-ratio.jpg 343w, https://www.policymed.com/wp-content/uploads/2023/10/Medical-loss-ratio-300x129.jpg 300w" sizes="auto, (max-width: 343px) 100vw, 343px" /></div>Most people know the “middleman” drives up the cost of everything, but few Americans see how a “middleman” in healthcare is contributing to spiraling costs. The general public, and surprisingly many physicians, don’t know the Affordable Care Act requires insurance companies to spend at least 80 to 85 percent of their premium dollars on medical […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="343" height="147" src="https://www.policymed.com/wp-content/uploads/2023/10/Medical-loss-ratio.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2023/10/Medical-loss-ratio.jpg 343w, https://www.policymed.com/wp-content/uploads/2023/10/Medical-loss-ratio-300x129.jpg 300w" sizes="auto, (max-width: 343px) 100vw, 343px" /></div><p>Most people know the “middleman” drives up the cost of everything, but few Americans see how a “middleman” in healthcare is contributing to spiraling costs.</p> <p>The general public, and surprisingly many physicians, don’t know the Affordable Care Act requires insurance companies to spend at least 80 to 85 percent of their premium dollars on medical care. The MLR or Medical Loss Ratio states if an insurer exceeds that profit in any year, they will fall out of compliance. Under the Affordable Care Act, the insurer is required to provide a rebate to their customers from the profits.</p> <p>This sounds great in theory. But in reality, this mandate discourages insurance companies from looking for the most cost-effective solutions. It disincentives insurers from looking for areas to lower costs because if they lower costs and increase profits, they will fall out of compliance.</p> <p>This mandate inserts yet another middleman into the healthcare system and clinicians in the trenches know this creates an impractical incentive to save money amongst private market health insurers.</p> <p><b>Why MLR Mandate Disincentives Innovation and Cost Savings with Insurers</b></p> <p>Here’s a more personal example that demonstrates how the MLR destroys innovation and doesn’t lower healthcare costs.</p> <p>Months after the ACA was established, I launched a care model entitled OrthoNOW®. The goal was simple: provide initial orthopedic care at the right time, by the right clinician. This meant avoiding expensive emergency rooms for the majority of orthopedic maladies, and the general urgent care center, where a primary care physician or mid-level provider historically doesn’t have the clinical expertise to diagnose most musculoskeletal issues.</p> <p>In fact, many facilities do not have any diagnostic modalities, such as xray or ultrasound, to even appropriately assess these walk-in patients. As an upper limb specialist who typically sees patients that have made 2-3 visits before coming to me, I thought this would be a boom to our healthcare delivery process within our South Florida community. That did not turn out to be the case and even now there is apathy amongst the health insurance industry.</p> <p>Another reason why MLR destroys innovation revolves around profits.</p> <p>Under this initiative, are not incentivized to save money or increase profits. OrthoNOW® is less expensive than emergency room visits, but cost savings is not embraced partially because of MLR. Remember, if the insurance company saves too much much money, they can come out of compliance with the 80 percent rule.</p> <p>I have seen this time and time again where an insurer is not interested in newer protocols that save a great deal of money. It creates a catch-22 dilemma.</p> <p>While everyone can argue about the pros and cons of the Affordable Care Act, the MLR requirements clearly work against the goal of driving down overall US healthcare costs.</p> <p>Common sense comments from friends lauded my initiative, but they did not understand MLR, nor did I at the time. They stated “The insurance companies will love this since it saves them money”. You would think.</p> <p>My example is not alone.</p> <p>There are many healthcare delivery innovations, including multiple digital health initiatives, that are not “covered” or funded by insurance carriers. Paradoxically, they would save too much money. If a carrier drastically reduces emergency room visits and steers these urgent care patients to a less costly environment, the cost savings will lower their clinical expenditures relative to their admin costs as well.</p> <p>Understanding this concept was perhaps the most valuable outcome of writing a book on healthcare delivery. During the initial 10 weeks of the pandemic drastic lockdown, I penned “<a href="https://www.amazon.com/Healthcare-Trenches-Barriers-Providers-Perspective-ebook/dp/B088PSH2RL">Healthcare from the Trenches: An Insider Account of the Complex Barriers of US Healthcare from the Providers and Patients’ Perspective</a>”. I came to understand the reason for our stifled innovation as largely stemming from the MLR. It is time to reverse that mandate and truly stimulate and support healthcare delivery cost savings… NOW.</p> <p><strong>About the Author</strong></p> <p>Orthopedic surgeon Alejandro Badia, MD, FACS is the founder of <a href="https://drbadia.com/">Badia Hand to Shoulder Center </a>and <a href="https://www.orthonowcare.com/orthobiologics/">OrthoNOW®</a> – the first national network of orthopedic walk-in centers, powered by a digital health app and telehealth platform. Dr. Badia is also author of the health care book, <a href="https://www.amazon.com/Healthcare-Trenches-Barriers-Providers-Perspective-ebook/dp/B088PSH2RL">Healthcare from the Trenches</a>, which has become an international best seller among the health care sector.</p> <p> </p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2023/10/insurance-medical-loss-ratio-mandate-effect-on-healthcare-innovation.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>The Uphill Battle: Addressing Insurance Denials for Essential Health Benefits Under ACA</title> <link>https://www.policymed.com/2023/10/the-uphill-battle-addressing-insurance-denials-for-essential-health-benefits-under-aca.html</link> <comments>https://www.policymed.com/2023/10/the-uphill-battle-addressing-insurance-denials-for-essential-health-benefits-under-aca.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Fri, 06 Oct 2023 08:01:41 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Insurance]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=16449</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="275" height="183" src="https://www.policymed.com/wp-content/uploads/2023/10/Insurance-denials.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" /></div>By Norman Means, MD Section 1302 of the Patient Protection and Affordable Care Act (“ACA” or Obamacare), codified at 42 U.S.C. § 18022, mandates that specific health plans include coverage for “Essential Health Benefits” (EHB). Within these EHBs are “preventive and wellness services,” incorporating all screening recommendations from the United States Preventive Services Task Force […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="275" height="183" src="https://www.policymed.com/wp-content/uploads/2023/10/Insurance-denials.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" /></div><p>By Norman Means, MD</p> <p>Section 1302 of the Patient Protection and Affordable Care Act (“ACA” or Obamacare), codified at 42 U.S.C. § 18022, mandates that specific health plans include coverage for “Essential Health Benefits” (EHB). Within these EHBs are “preventive and wellness services,” incorporating all screening recommendations from the United States Preventive Services Task Force (USPSTF) graded with either an “A” or “B” level recommendation.</p> <p>Tammy Atwood, a pseudonym, is a 54-year-old current cigarette smoker who recently had her annual check-up with her new primary care doctor. Despite being asymptomatic and seemingly in good health, her 35 pack-year history of smoking prompted her physician to recommend a low-dose CT of the chest to screen for lung cancer— a test accorded a “B” level recommendation by the USPSTF. The criteria for this screening include age between 50 to 80 years, a minimum of 20 pack-year smoking history, current smoking status (or having quit within the last 15 years), absence of health problems substantially limiting life expectancy, and willingness to undergo curative lung surgery. Meeting all requirements and her health plan being under the ACA-mandate, a low-dose lung CT was arranged.</p> <p>However, Tammy’s health plan promptly denied coverage for the screening test, citing a “lack of medical necessity.” Per the carrier’s explanation, the denial arose because the office staff indicated the presence of any cancer symptoms as “unknown” in the insurer’s pre-test questionnaire. After a 30-minute phone appeal, Tammy’s physician secured approval for the test.</p> <p>Such denials have become distressingly routine, contradicting the explicit statutory language of the ACA. “Insurers have used various tactics to evade covering portions or entire preventive services that ought to be covered,” states Laura Hermer, J.D., a Professor of Health Law at Mitchell Hamline School of Law in St. Paul, MN.</p> <p>In Tammy’s case, the insurance carrier’s actions blatantly contradicted the ACA’s mandatory requirements and the USPSTF’s established cancer criteria. The insurer exploited a clerical staff member’s lack of knowledge of any symptoms to justify their denial, using the ambiguous criteria of “medical necessity,” rather than a confirmed statement regarding lung cancer symptoms.</p> <p>Government efforts to address these abuses of the ACA’s preventive services mandate have been largely ineffective. “These practices persist, despite ongoing efforts by the federal Department of Health and Human Services to eradicate them,” remarks Professor Hermer.</p> <p>Quantifying the human cost of such routine denials of cancer screening is challenging due to a lack of public data on unappealed denied tests. However, the toll on physician time is evident. Tammy’s physician, seeking anonymity to avoid repercussions, shared, “Multiply the hours wasted every week on hold with insurance companies by the number of primary care physicians and midlevel providers nationwide, and the societal burden surely surpasses any savings from avoiding covering medically unnecessary testing.”</p> <p>Transparency holds the key to resolving these issues. Federal regulators should consider mandating insurers to disclose appeals data, including the rates of non-appealed initially denied cancer screenings. Moreover, insurers must be compelled to reveal the average duration of physician appeals calls and the success rates of such appeals. “These ‘peer-to-peer’ calls almost invariably result in approval by the insurance company physician,” says Tammy’s physician, “so why are we wasting time making these calls in the first place?” Enforcing the mandates of the ACA will ensure that those who stand to benefit most from cancer screening do not encounter unnecessary roadblocks in their healthcare journey.</p> <p>About the author: Norman Means, MD is a medical professional with over 30 years’ experience in rural healthcare, and currently a third-year law student.</p> <p>If you identify a healthcare policy gap, please feel free to submit a guest editorial.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2023/10/the-uphill-battle-addressing-insurance-denials-for-essential-health-benefits-under-aca.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>Ongoing Litigation Over ACA Provisions that Mandate Health Coverage</title> <link>https://www.policymed.com/2023/05/ongoing-litigation-over-aca-provisions-that-mandate-health-coverage.html</link> <comments>https://www.policymed.com/2023/05/ongoing-litigation-over-aca-provisions-that-mandate-health-coverage.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Fri, 19 May 2023 08:47:01 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Medical Legal]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=16041</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34.jpg 1200w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div>On March 30, 2023, the U.S. District Court for the Northern District of Texas vacated actions taken by HHS to implement provisions of the Affordable Care Act (ACA) that require health insurance plans to include coverage for certain preventive healthcare services. Judge Reed O’Connor issued the decision and enjoined HHS from enforcing the ACA requirements […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34.jpg 1200w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2022/07/stencil.default-34-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div><p>On March 30, 2023, the <a href="https://litigationtracker.law.georgetown.edu/wp-content/uploads/2023/01/Braidwood_20230330_OPINION-and-ORDER-on-Remedies.pdf">U.S. District Court for the Northern District of Texas vacated actions taken</a> by HHS to implement provisions of the Affordable Care Act (ACA) that require health insurance plans to include coverage for certain preventive healthcare services. Judge Reed O’Connor issued the decision and enjoined HHS from enforcing the ACA requirements after previously finding that the task force that recommended them was not constitutionally appointed.</p> <p><strong>Background</strong></p> <p>The ACA empowers the U.S. Preventive Service Task Force (USPSTF), the Health Resources and Services Administration (HRSA), and the Advisory Committee on Immunization Practice (ACIP) to determine the types of preventive care that must be covered by health insurers under the ACA. Since the ACA was enacted, these three agencies have issued pronouncements requiring health insurers to cover, at no cost, preexposure prophylaxis (PrEP) drugs for HIV and sexually transmitted disease screenings. These “preventive care mandates,” as the court referred to them, are all recommended by the USPSTF.</p> <p>The plaintiffs in the case, which included six individuals and two businesses, objected to the preventive care mandates on religious or personal grounds and claimed that they violated the U.S. Constitution and the Religious Freedom Restoration Act (RFRA). In September 2022, Judge O’Connor agreed with respect to the preventive care mandates recommended by the USPSTF, because its members are not confirmed by the U.S. Senate, and neither HHS nor other constitutional officials review their recommendations.</p> <p><strong>More on Ruling</strong></p> <p>The court broadly prohibited HHS from enforcing the ACA preventive services requirement with respect to any USPSTF recommendations issued on or after March 23, 2010 (the date of the ACA’s enactment). As a result of this order, commercial plans could potentially seek to limit coverage or add cost sharing for services that were more recently recommended by USPSTF. HHS <a href="https://aspe.hhs.gov/sites/default/files/documents/786fa55a84e7e3833961933124d70dd2/preventive-services-ib-2022.pdf">estimates</a> that the preventive services requirement governs coverage for 152 million people with private insurance.</p> <p>The court also expanded its ruling with respect to PrEP and religious freedom. Whereas the court had previously ruled that a plan sponsor could potentially claim a religious exemption under RFRA from complying with the PrEP coverage mandate, the court’s latest order appears to conclude that individuals who purchase health coverage can also claim an RFRA exemption from the PrEP coverage requirement.</p> <p>HHS has already appealed the district court’s ruling to the U.S. Court of Appeals, Fifth Circuit. Congress could theoretically correct the appointments clause issue in the ACA preventive services requirement by, for example, making USPSTF’s recommendations subject to ratification by the HHS Secretary. <a href="https://www.healthaffairs.org/content/forefront/repairing-us-preventive-services-task-force-after-i-braidwood-v-becerra-i">Other recommendations have been made on this issue</a>. Meanwhile, states have the authority to require state-regulated insurance to continue covering all USPSTF-recommended services without cost sharing.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2023/05/ongoing-litigation-over-aca-provisions-that-mandate-health-coverage.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>Biden Administration Proposes Requiring Standardized Plan Designs on ACA Exchanges</title> <link>https://www.policymed.com/2022/01/biden-administration-proposes-requiring-standardized-plan-designs-on-aca-exchanges.html</link> <comments>https://www.policymed.com/2022/01/biden-administration-proposes-requiring-standardized-plan-designs-on-aca-exchanges.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Thu, 27 Jan 2022 09:48:20 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[CMS]]></category> <category><![CDATA[HHS]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=14931</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="488" height="487" src="https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N.jpg 488w, https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N-300x300.jpg 300w, https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N-150x150.jpg 150w, https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N-100x100.jpg 100w" sizes="auto, (max-width: 488px) 100vw, 488px" /></div>The Biden administration is aiming to require insurers to offer standardized plan designs on the Affordable Care Act’s (ACA’s) exchanges. As part of the Centers for Medicare & Medicaid Services’ (CMS’) 2022 Notice of Benefit and Payment Parameters rule, payers would have to offer standardized plan options for every product network type, plan tier type […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="488" height="487" src="https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N.jpg 488w, https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N-300x300.jpg 300w, https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N-150x150.jpg 150w, https://www.policymed.com/wp-content/uploads/2020/12/ChUDHq1N-100x100.jpg 100w" sizes="auto, (max-width: 488px) 100vw, 488px" /></div><p>The Biden administration is aiming to require insurers to offer standardized plan designs on the Affordable Care Act’s (ACA’s) exchanges. As part of the Centers for Medicare & Medicaid Services’ (CMS’) 2022 Notice of Benefit and Payment Parameters <a href="https://public-inspection.federalregister.gov/2021-28317.pdf">rule</a>, payers would have to offer standardized plan options for every product network type, plan tier type and plan classification. CMS said the goal is to allow consumers to have an easier shopping experience. As standardized plans share a uniform cost-sharing structure, it’s simpler to compare across plans.</p> <p>“We are building a more competitive, transparent and affordable health care market,” <a href="https://www.cms.gov/newsroom/press-releases/hhs-make-coverage-more-accessible-and-affordable-millions-americans-2023">said</a> Department of Health and Human Services Secretary Xavier Becerra. “At the end of the day, health care should be a right for everyone, not a privilege for some.”</p> <p><strong>More on Rule</strong></p> <p>Under the proposed rule, HHS is offering several changes to premium and risk adjustment rates as well as the risk adjustment model. HHS is proposing the following changes to the risk adjustment model to begin in benefit year 2023: (1) the addition of a two-stage weighted approach to the adult and child models; (2) the removal of the current severity illness factors from the adult models and the addition of an interacted hierarchical condition category (HCC) count model specification to the adult and child models; and (3) the replacement of the current enrollment duration factors in the adult models with HCC-contingent enrollment duration factors.</p> <p>HHS also proposed the following changes to model recalibration for the 2023 benefit year risk adjustment models: (1) using the 2017, 2018, and 2019 enrollee-level EDGE data for model recalibration; (2) applying a market pricing adjustment to the plan liability associated with Hepatitis C drugs; and (3) using the fourth quarter prescription drug categories mapping document for each benefit year of recalibration data, with the exception of 2017 enrollee-level EDGE data.</p> <p>HHS is also promoting several policies to promote health equity. As a result of the Department’s 2020 final rule implementing section 1557 of the ACA, gender identity and sexual orientation were removed from being included as the bases for discrimination and subject to non-discrimination protections. HHS is now proposing to once again include these terms in its nondiscrimination policy, effectively prohibiting Marketplaces, issuers, agents, and brokers from discriminating against consumers based on sexual orientation and gender identity. Further, the proposed rule seeks to refine the essential health benefits (EHB) nondiscrimination policy to require that benefit designs be based on clinical evidence, including factors surrounding discrimination based on age, health conditions, and sociodemographic factors.</p> <p>Additionally, HHS is proposing to conduct network adequacy reviews in all FFE states, with the exception of states that have their own standard already in place as stringent as the federal standard which also conduct their own reviews. Reviews are to take place prospectively during the Qualified Health Plan (QHP) certification process. Issuers that are unable to meet the standards would be able to submit justification to explain why this is the case and how they are aiming to do so in the future. Further, the HHS is proposing to collect data from insurers on which of their network providers offer telehealth services.</p> <p>Also under the proposed rule, issuers in the FFEs and SBE-FPs would be required to offer plans with standardized cost-sharing parameters at every product network type, metal level, and throughout every service area that they offer non-standardized options in PY 2023. For example, an issuer must offer a standardized gold plan in a particular service area if that issuer offers a non-standardized gold plan in that same service area. To this end, HHS has created two sets of standardized plan options at all of the levels of coverage, each designed specifically to meet the cost-sharing laws in different sets of states. Additionally, HHS is also proposing to display these standardized options differentially on HealthCare.gov.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2022/01/biden-administration-proposes-requiring-standardized-plan-designs-on-aca-exchanges.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>AHA v. Azar Reversed by D.C. Court of Appeals</title> <link>https://www.policymed.com/2020/10/aha-v-azar-reversed-by-d-c-court-of-appeals.html</link> <comments>https://www.policymed.com/2020/10/aha-v-azar-reversed-by-d-c-court-of-appeals.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Thu, 15 Oct 2020 08:58:14 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Medical Legal]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=13883</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1.jpg 1200w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div>This summer, the United States Court of Appeals for the District of Columbia reversed the United States District Court for the District of Columbia’s ruling in American Hospital Association (AHA) v. Azar, finding that the United States Department of Health and Human Services (HHS) properly exercised its authority in permitting the Centers for Medicare and […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="1200" height="800" src="https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1.jpg 1200w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-1024x683.jpg 1024w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-768x512.jpg 768w, https://www.policymed.com/wp-content/uploads/2020/08/stencil.default-1-450x300.jpg 450w" sizes="auto, (max-width: 1200px) 100vw, 1200px" /></div><p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">This summer, the </span><a href="https://www.cadc.uscourts.gov/internet/opinions.nsf/E27BC5B064ED8035852585A80052C843/$file/19-5352-1852218.pdf"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">United States Court of Appeals for the District of Columbia</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;"> reversed the </span><a href="https://casetext.com/case/am-hosp-assn-v-azar-5"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">United States District Court for the District of Columbia’s ruling</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;"> in American Hospital Association (AHA) v. Azar, finding that the United States Department of Health and Human Services (HHS) properly exercised its authority in permitting the Centers for Medicare and Medicaid Services (CMS) to implement a service-specific, non-budget-neutral reimbursement cut under the Outpatient Prospective Payment System (OPPS).</span></p> <p class="MsoNormal"><b><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">Background</span></b></p> <p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">The way the OPPS system is set up, each year CMS sets the rates at which Medicare will reimburse hospitals for providing outpatient services under OPPS – the parameters of the system are statutorily set and any changes to OPPS must be budget neutral. However, even though the payment rate is controlled by OPPS, the quantity of services is not, meaning an increase in the services provided will result in an increase in Medicare expenditures. Because of that, Congress directed HHS in subparagraph (2)(F) of the OPPS statute, to “develop a method for controlling unnecessary increases in the volume of covered services.”</span></p> <p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">Typically, Congress has used Section 603 of the </span><a href="https://www.congress.gov/114/plaws/publ74/PLAW-114publ74.pdf"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">Bipartisan Budget Act of 2015</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;"> to address the issue of rising outpatient services being performed at hospital off-campus provider-based departments. That has helped to reduce the payment rates for services furnished at those locations that started/opened after the statute’s enactment, but did not alter the reimbursement rates for existing off-campus provider-based departments.</span></p> <p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">Then, in 2019, CMS </span><a href="https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-15958.pdf"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">proposed to exercise its authority</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;"> and “develop a method for controlling” the increase, specifically proposing to cut reimbursement rates for evaluation and management services to all off-campus provider-based departments to the amount that CMS pays to freestanding physician offices who provide the same service. However, CMS wanted to implement the budget cut in a non-budget-neutral manner and indicated that it did not believe the budget-neutral requirement applied to methods for controlling volume. CMS </span><a href="https://www.govinfo.gov/content/pkg/FR-2018-11-21/pdf/2018-24243.pdf"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">then finalized the proposed rule</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;"> and </span><a href="https://www.aha.org/system/files/2018-12/complaint-challenging-site-neutral-payment-policy181204.pdf"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">AHA filed suit</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">.</span></p> <p class="MsoNormal"><b><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">Lower Court Ruling</span></b></p> <p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif; color: black; background: white;">In its decision, the </span><a href="https://casetext.com/case/am-hosp-assn-v-azar-5"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif; background: white;">lower court agreed with the AHA</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif; color: black; background: white;"> and set aside the regulation implementing the rate reduction, finding that the “method” developed by CMS “is impermissible and violates its obligations under the statute.”. In the </span><a href="https://casetext.com/case/am-hosp-assn-v-azar-5"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif; background: white;">decision</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif; color: black; background: white;">, the Court emphasized that “Congress provided great detail in directing how CMS should develop and adjust relative payment weights…This extraordinarily detailed scheme results in a relative payment system which ensures that payments for one service are rationally connected to the payments for another and satisfies specific policies considered by Congress. And so that this system retains its integrity, CMS is required to review annually the relative payment weights of [off-campus provider department] services and their adjustments based on changes in cost data, medical practices and technology, and other relevant information.”</span></p> <p class="MsoNormal"><b><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">United States Court of Appeals for the District of Columbia Ruling</span></b></p> <p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">The Court of Appeals, however, </span><a href="https://www.cadc.uscourts.gov/internet/opinions.nsf/E27BC5B064ED8035852585A80052C843/$file/19-5352-1852218.pdf"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">reversed that decision</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">, concluding that following the <i>Chevron </i>precedent and rule means that HHS’s reduction in reimbursement for E&M services provided by off-campus provider-based departments qualifies as a “method for controlling unnecessary increases in the volume of covered [outpatient] services” and was not “unambiguously forbid[den]” by Congress. Therefore, because the challenged rate cut is a method described under subparagraph (2)(F) of the OPPS statute, judicial review of that action is precluded. Neither the Appeals Court, nor the district court has jurisdiction over the challenge presented by AHA.<span style="mso-spacerun: yes;"> </span></span></p> <p class="MsoNormal"><b><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">What Does This Mean?</span></b></p> <p class="MsoNormal"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">Unfortunately, </span><a href="https://www.natlawreview.com/article/appellate-court-s-reversal-aha-v-azar-poses-existential-threat-to-medicare"><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">as noted by the National Law Review</span></a><span style="font-size: 12.0pt; font-family: 'Arial',sans-serif;">, this decision will likely result in the unpredictability of “OPPS as a payment system governed by steadfast rules mandated by Congress, going forward” and that “CMS is likely to devise increasingly aggressive interpretations of the provisions at issue here,” further putting the service and payment delivery systems at risk.<span style="mso-spacerun: yes;"> </span></span></p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2020/10/aha-v-azar-reversed-by-d-c-court-of-appeals.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>The Open Payments Database Has Increased Transparency, But Decreased Doctor-Patient Trust</title> <link>https://www.policymed.com/2019/05/the-open-payments-database-has-increased-transparency-but-decreased-doctor-patient-trust.html</link> <comments>https://www.policymed.com/2019/05/the-open-payments-database-has-increased-transparency-but-decreased-doctor-patient-trust.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Thu, 09 May 2019 09:01:25 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Open Payments]]></category> <category><![CDATA[Physician Payment Disclosure]]></category> <category><![CDATA[Physician Payment Sunshine Act]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=12245</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="299" height="168" src="https://www.policymed.com/wp-content/uploads/2019/05/physican-patient-trust.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" /></div>The Affordable Care Act, which was passed in 2010, required the Centers for Medicare & Medicaid Services (“CMS”) to establish a publicly-accessible database with the goal of increasing transparency about financial relationships between the drug and medical device industry and healthcare providers. Such data could then be used to provide insight into potential conflicts of […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="299" height="168" src="https://www.policymed.com/wp-content/uploads/2019/05/physican-patient-trust.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" /></div><p>The Affordable Care Act, which was passed in 2010, <a href="https://www.cms.gov/OpenPayments/About/Law-and-Policy.html">required the Centers for Medicare & Medicaid Services (“CMS”) to establish a publicly-accessible database</a> with the goal of increasing transparency about financial relationships between the drug and medical device industry and healthcare providers. Such data could then be used to provide insight into potential conflicts of interest. The result is the <a href="https://openpaymentsdata.cms.gov/about">CMS Open Payments website</a>. Open Payments collects and publishes data relating to payments to healthcare providers for various activities, including “research, meals, travel, gifts, or speaking fees.” Open Payments contains data from August 2013 to December 2017.</p> <p>While the Open Payments program was intended to increase transparency, some were concerned that there would be unintended consequences of disclosing such information. A <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2730473?resultClick=3">recent study</a> out of the University of Pennsylvania suggests that one such unintended consequence has indeed come to pass. Genevieve Kanter, PhD, and her colleagues published an article on April 12, 2019 in JAMA Open Network, directed to the effect of the Open Payments program on patient trust of their doctors. In the study, the authors conducted a longitudinal study wherein 1,388 US adults were surveyed prior to the launch of the Open Payments website, and again two-years after the website launch. The authors found a 2.7% decrease in each participant’s trust in their own physician, even when the participant knew that their doctor had not received any industry payments. The authors concluded that “public disclosure may have resulted in negative reputational spillovers affecting ‘pharma-free’ physicians with industry ties.”</p> <p>The BMJ has also gotten in on the transparency trend. On April 16, 2019, the <a href="https://www.bmj.com/content/365/bmj.l1706">BMJ announced</a> a new stream of content to revisit the countervailing goals of collaboration with industry to develop new products that improve health, and financial conflicts of interest that “jeopardize the integrity of science, the objectivity of education, the quality of care, and public trust in medicine.” The goal of this effort is to identify and respond to commercial influences on healthcare, and to determine when industry involvement is truly necessary. When such involvement is not necessary, the BMJ wants to forge independence from industry in order to strengthen trust in the healthcare system.</p> <p><a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.23.4.124?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&">Studies have shown</a> that trust is a crucial component of the doctor-patient relationship. Specifically, patient trust in their doctor predicts certain healthy behaviors, such as the use of preventative services, intended or reported adherence to treatment recommendations, and continuity with providers. Thus, the various initiatives to increase transparency may actually produce the opposite of their desired effect, if that increase in transparency leads to a decrease in doctor-patient trust, and a corresponding decrease in patients’ health.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2019/05/the-open-payments-database-has-increased-transparency-but-decreased-doctor-patient-trust.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> <item> <title>House Democrats Propose New Sweeping Health Care Legislation</title> <link>https://www.policymed.com/2019/04/house-democrats-propose-new-sweeping-health-care-legislation.html</link> <comments>https://www.policymed.com/2019/04/house-democrats-propose-new-sweeping-health-care-legislation.html#respond</comments> <dc:creator><![CDATA[Thomas Sullivan]]></dc:creator> <pubDate>Tue, 02 Apr 2019 09:24:32 +0000</pubDate> <category><![CDATA[Affordable Care Act]]></category> <category><![CDATA[Congress]]></category> <category><![CDATA[NEW]]></category> <guid isPermaLink="false">https://www.policymed.com/?p=12107</guid> <description><![CDATA[<div style="margin-bottom:20px;"><img width="900" height="600" src="https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2.jpg 900w, https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2-768x512.jpg 768w" sizes="auto, (max-width: 900px) 100vw, 900px" /></div>On March 26, 2019, in the midst of Affordable Care Act invalidation discussions, Speaker of the United States House of Representatives Nancy Pelosi announced a wide-ranging health care proposal that would further cement the ACA, and perhaps even taken it a step further. The Proposal The proposal reaches multiple facets of the health care industry, […]]]></description> <content:encoded><![CDATA[<div style="margin-bottom:20px;"><img width="900" height="600" src="https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2.jpg" class="attachment-post-thumbnail size-post-thumbnail wp-post-image" alt="" decoding="async" loading="lazy" srcset="https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2.jpg 900w, https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2-300x200.jpg 300w, https://www.policymed.com/wp-content/uploads/2018/07/0905-Congress_Returns.2-768x512.jpg 768w" sizes="auto, (max-width: 900px) 100vw, 900px" /></div><p>On March 26, 2019, in the midst of Affordable Care Act invalidation discussions, Speaker of the United States House of Representatives Nancy Pelosi announced a <a href="https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/Health%20Care%20Bill%20Text.pdf">wide-ranging health care proposal</a> that would further cement the ACA, and perhaps even taken it a step further.</p> <p><strong>The Proposal</strong></p> <p>The <a href="https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/Health%20Care%20Bill%20Section%20by%20Section.pdf">proposal reaches multiple facets of the health care industry</a>, including attempting to reduce health care premiums by capping out-of-pocket costs at 10 percent of income and expanding tax credits for those beyond 400 percent of the federal poverty line. It also creates a national reinsurance program in an attempt to offset high medical bills for insurers and attempt to keep premium increases from continuing to rise.</p> <p>The bill also <a href="https://energycommerce.house.gov/sites/democrats.energycommerce.house.gov/files/documents/Health%20Care%20Bill%20One%20Pager.pdf">reinstates the “preexisting condition guarantee”</a> where those with pre-existing conditions are guaranteed to be covered. It also disallows non-ACA compliant plans from being sold and reaffirms the list of essential health care benefits that are to be covered by all plans, originally found in the ACA. The proposal also requires the current administration to budget federal money for enrollment outreach, a budget that has been dramatically cut since the Trump Administration came to Washington.</p> <p>One thing that some may find “missing” from the bill is the failure to restore the cost-sharing payments to health insurers that the Trump Administration ended. This is not an oversight, but is intentional, as many have wound up receiving greater federal aid without the cost-sharing payments.</p> <p>According to a senior aide, <a href="https://www.vox.com/policy-and-politics/2019/3/26/18282103/aca-obamacare-news-house-democrats-legislation-doj">the bill is not likely to be passed as a single package</a>, but instead is likely to be brought up for discussion in individual provision pieces. This will also allow members of either political party to show where they stand on certain issues as it relates to health care.</p> <p>It should be noted that the proposal does not make any mention of “Medicare for All,” a popular concept embraced by many on the left-leaning side of the political aisle. This was likely by design, as Pelosi has been known to oppose the concept of single-payer, raising questions about how it would be paid for. However, the door is not closed, as the <a href="https://www.vox.com/policy-and-politics/2019/3/26/18282103/aca-obamacare-news-house-democrats-legislation-doj">senior aide mentioned earlier also noted</a>, “This doesn’t displace a discussion about a public option, a Medicare buy-in, Medicare-for-all.”</p> <p><strong>Support</strong></p> <p>Some political groups have already come out in support of the proposal, including <a href="https://www.protectourcare.org/protect-our-care-applauds-speaker-pelosi-house-democrats-aggressive-lower-costs-better-care-legislation/">Protect Our Care, a progressive group, who stated</a>, “In all, the bill’s extended tax credits, reinsurance programs and premium assistance would cut premiums for all ACA-compliant plans sold on the individual market, reducing premiums or deductibles for 13 million with individual market coverage and creating lower cost options for 12 million uninsured people eligible for coverage through the marketplace.”</p> <p><strong>Opposition</strong></p> <p>However, like many topics in Washington, DC today, this is not a slam-dunk proposal fully supported by either side of the “political aisle.” Republicans have <a href="https://www.chicagotribune.com/news/nationworld/ct-trump-obamacare-aca-affordable-care-repeal-act-20190326-story.html">long been trying to invalidate the ACA</a> and have it declared unconstitutional, while progressives like <a href="http://nymag.com/intelligencer/2019/03/bernie-sanders-wont-back-house-democrats-obamacare-bill.html">Bernie Sanders want to get rid of everything</a> and institute single-payer health care.</p> <p><strong>Conclusion</strong></p> <p>Even if the bill passes the Democrat-controlled House of Representatives, it is surely dead on arrival in the Republican-controlled Senate. The introduction of this bill may simply be a political move to hold elected politicians’ feet to the political fires the base of either party are lighting up.</p> ]]></content:encoded> <wfw:commentRss>https://www.policymed.com/2019/04/house-democrats-propose-new-sweeping-health-care-legislation.html/feed</wfw:commentRss> <slash:comments>0</slash:comments> </item> </channel> </rss>