Stay ahead of the latest regulatory shifts and healthcare breaking news with Headlines from the Hill.
In this month’s edition you will find:
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- Clinical staffing ratios: American Hospital Association challenges CMS minimum staffing rule.
- Medicare Advantage insurers: Denying access to post-acute care services.
- MedPAC debates value of the Medicare Advantage program benefits.
- Managed Care: Ongoing actions that have negative impact on patient access to care and hospital payment.
- Physician Fee Schedule: What you need to know from inflation and adjustments.
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Clinical staffing ratios: American Hospital Association challenges CMS minimum staffing rule.
The American Hospital Association (AHA) has submitted a friend-of-the-court brief to the U.S. District Court for the Northern District of Texas, contesting the Centers for Medicare & Medicaid Services (CMS) minimum staffing requirement for nursing homes.
The new CMS rule mandates that all nursing homes must have a registered nurse (RN) available for direct resident care 24/7. It also specifies minimum staffing hours per day: 0.55 hours for RNs, 2.45 hours for nursing assistants, and a total of 3.48 hours for all nursing staff.
Nursing homes might comply by overworking their current staff, leading to increased burnout, or by hiring from a limited labor pool, which would reduce the availability of qualified staff across all healthcare providers. Last year, the AHA urged CMS to reconsider the mandate and instead develop strategies that focus on safe staffing practices in nursing facilities, centered on patient and workforce needs.
The AHA further states that this mandate is "not just an overly simplistic and costly solution to the nursing shortage; it is no solution at all.” The AHA argues that CMS's claim of establishing a “minimum baseline” for all facilities is misleading. According to their data, 79% of long-term care facilities will need to increase staffing levels to meet the new requirements, which exceed existing state standards. The AHA warns that this unfunded mandate will not effectively address the nursing shortage and could actually worsen the situation.
Medicare Advantage insurers: Denying access to post-acute care services.
The U.S. Senate Permanent Subcommittee on Investigations issued an alarming report outlining how Medicare Advantage (MA) insurers are denying patient access to post-acute care services. The report recommended that CMS do the following three things:
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- Begin collecting prior authorization information broken down by service category.
- Conduct targeted audits if insurer prior authorization data reveals notable increases in adverse determination rates.
- Expand regulations for utilization management committees to prevent predictive technologies from unduly influencing human reviewers.
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The committee’s findings on the largest three Medicare Advantage insurers were as follows:
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- UnitedHealthcare, Humana and CVS deny prior authorization requests for post-acute care (PAC) services (rehabilitation hospitals, long-term acute care hospitals and skilled nursing facilities) for Medicare Advantage enrollees at a substantially higher rate than for other types of care. By 2022, the insurance companies were denying about one out of every four PAC requests compared to 1.5-8.8% of other prior authorization requests.
- At the same time that UnitedHealthcare was trying to automate the prior authorization process, the denial rate increased astronomically from 8.7% to 22.7%.
- CVS subjected additional PAC to the prior authorization process to generate additional savings.
- After Humana’s prior authorization training emphasized denials, denials at long-term acute care hospitals jumped to 61.4%.
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A strategic partner can help hospitals navigate the complexities of MA denials and therefore increase appropriate care access for patients requiring critical post-acute services, such as inpatient rehabilitation.
MedPAC debates value of the Medicare Advantage program benefits.
The Medicare Payment Advisory Commission (MedPAC) concluded that it is unable to answer key questions about the value of extra benefits within the Medicare Advantage program and may need to wait several more years for better data from CMS.
MedPAC is undertaking the analysis as part of its annual review of MA, which now covers a majority of America’s seniors. MedPAC, which has been critical about the cost of MA, is analyzing whether taxpayers and beneficiaries get their money’s worth for what Medicare spends on extra benefits in the MA program. Such supplemental benefits cost $83 billion a year, MedPAC said, or $2,500 per program enrollee. MedPAC noted that extra spending in MA raises Part B premiums for all Medicare beneficiaries, whether or not they have access to supplemental benefits.
What you need to know:
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- Lack of adequate data makes it hard to assess the value of $83 billion that Medicare spends annually for supplemental benefits in Medicare Advantage plans, according to a MedPAC analysis.
- It is similarly difficult to determine how many MA enrollees are using popular extra benefits including dental, vision and hearing services, MedPAC said.
- Commissioners differed sharply on whether MA plans are overpaid but appeared to coalesce around the need for greater transparency in data and a desire to make it easier for beneficiaries to weigh their options if they prefer a private plan to fee-for-service Medicare.
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Managed Care: Ongoing actions that have negative impact on patient access to care and hospital payment.
Managed care is delaying and denying patients’ access to care through prior authorization and other harmful practices, particularly in Medicare Advantage (MA) plans. This threatens patients’ access to services that would otherwise be covered under traditional Medicare, jeopardizing patient safety and undermining hospitals’ ability to provide high-quality, affordable services.
Several organizations, including Lifepoint, plan to work with lobbyists and federal trade associations to increase transparency, scrutiny and accountability for these abuses by demonstrating the real-life impact to patient care and by developing and supporting legislation, quality measures, regulations, research and other efforts to limit abuses. Updates will be shared in future editions of Healthcare Headlines from the Hill.
Physician Fee Schedule: What you need to know from inflation and adjustments.
MedPAC addressed issues around Physician Fee Schedule adequacy. The commission continues to find that Medicare beneficiaries’ access to clinician care is as good as that of privately insured individuals, yet there are concerns that Medicare’s payments under the physician fee schedule may not remain adequate to continue access to care for beneficiaries.
As background: The Physician Fee Schedule (PFS) covers payments for about 9000 clinician services and are performed in a wide variety of settings. Services can be discrete or a bundle of services (surgery and post operative visits) They are calculated using Relative Value Units (RVUs) and a conversion factor. The Medicare Access and CHIP Reauthorization Act (MACRA) currently influences the update rates for the PFS. MedPAC emphasizes the need to balance maintaining care access and managing Medicare spending through potential PFS reform and enhanced payment accuracy.
The following is what we need to know from the MedPAC public meeting to address proposed reforms to the Medicare PFS focusing on updates tied to inflation and adjustments to payment accuracy, emphasizing the need for reforms:
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- There are current concerns with fee schedule updates.
- MedPAC proposes adjusting PFS updates based on MEI growth.
- MedPAC highlights the need to reassess how RVUs are set and updated.
- Options include either revaluing or converting global surgical bundle codes and reforming indirect practice expenses.
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