Weekly Roundup (August 21-August 25, 2023)
Physician payment, coding, coverage, and quality reporting news highlights.
While traveling this week, I think I came up with another answer for “You Know You are a Health Policy Wonk If” How about, “You know you are a health policy wonk if you consider a visit to urgent care while on vacation fieldwork.” Happy Friday!
PAYMENT
Congressional Budget Office (CBO) Appoints 2023 Health Advisors. On August 22, 2023, the CBO announced its panel of 2023 Health Advisors. The panel consists of widely recognized experts in health policy and the healthcare sector. The CBO hosts an annual meeting with the advisors to gather their input.
The 2023 panel includes four physicians: Toyin Ajayi, MD, M.Phil (C-Founder and CEO of Cityblock Health); Thomas Lee, MSC, MD (Chief Medical Officer, Press Ganey Associates); David Meltzer, MD, PhD (Fanny L. Pritzker Professor, Chief of the Section of Hospital Medicine, Director of the Center for Health and the Social Sciences, and Chair of the Committee on Clinical and Translational Science, Department of Medicine, University of Chicago); and Lewis Sandy, MD, MBA (Co-founder and Principal, SuLu Consulting, LLC). Other members of note also include Michael Chernew, PhD (Chair of the Medicare Payment Advisory Commission) and John Haupert, MsC (Chairman, American Hospital Association Board of Trustees)
The CBO is legally required to produce a cost estimate for nearly every bill approved by a full committee of the House or the Senate, except for appropriation bills. The CBO also prepares analytic reports at the request of the Congressional leadership or the Chairmen or Ranking Members of committees or subcommittees.
PAYMENT INNOVATION AND QUALITY
Advanced Alternative Payment Model (APM) Incentive Payments for 2023 Announced. The Centers for Medicare and Medicaid Services (CMS) released information on incentive payments distributed in 2023 for the 2021 performance year. Established by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, eligible clinicians must meet certain participation thresholds in one or more Advanced Alternative Payment Models to qualify for a bonus payment.
2023 Payment Year
Number of clinicians (NPIs*): 226,681
Total Payments**: $643,591,255
Mean: $2,839
Median: $1,465
* This figure does not include QPs whose incentive payment was $0 because they had no eligible claims in the base year.
** This figure represents earned incentive payments, which may be higher than disbursements on the basis of application of Federal debt offsets, bank transaction failures, and other factors.
Individuals who have not received incentive payments may need to verify their billing information. To obtain the incentive payment, billing information must be verified by September 1, 2023. Further details are available on the Quality Payment Program website.
CMS Announces $1.8 Billion in Savings from the Medicare Shared Savings Program (MSSP) for 2022. On August 24, 2023, CMS announced that this was the sixth year that MSSPs demonstrated savings. In response to this announcement, accountable care organization (ACO) advocates have argued that this provides further evidence of the program's value and that bonus payments set to expire at the end of 2023 should be extended. MACRA established 5% bonus payments for qualified participants through the 2022 performance period (payable in 2024), which were then extended to 3.5% for 2023. The Value in Health Care Act (H.R. 5013) would extend incentives that expire at the end of the year.
PTAC Meets to Discuss Rural Participation in Population-based Total Cost of Care (PB-TCOC) Models. Registration is open for the public meeting, which will be held September 18-19., 2023. This meeting is part of a series of meetings hosted by PTAC on PB-TCOC models. The committee is also extending until September 13 the comment period on its solicitation for input on improving the management of care transitions. This feedback will help inform PTAC’s thinking on PB-TCOC and other models.
Established by the MACRA, PTAC is tasked by statute to review proposals for physician-based payment models and provide recommendations to the Department of Health and Human Services (HHS). To date, HHS has not implemented any models recommended by PTAC, and as a result, stakeholders have questioned the role of PTAC in developing payment models. In June 2020, PTAC released a new vision statement where it indicated it will “expand our communications with the Centers for Medicare & Medicaid Services (CMS) and stakeholders to identify opportunities to further inform and prioritize the work CMS, including the Center for Medicare & Medicaid Innovation (CMMI), and other policymakers are undertaking to modernize health care.”
CODING
CMS Will Not Implement New Place of Service (POS) Code -27 Outreach Site/Street. This POS code describes a non-permanent location on the street or other environment where services are provided to homeless individuals. It was created at the request of industry representatives, but Medicare has not identified a need for it. To be HIPAA compliant, contractors should be able to accept claims containing this code with its effective date, but at this time, such Medicare claims will be returned as not processable.
COVERAGE
CIGNA Reduces Prior Authorizations for Commercial Customers by 25 Percent. The health insurer made this announcement following a similar and recent move from UnitedHealthcare to reduce prior authorization procedures by 20 percent and ahead of an expected announcement by the Medicare agency to address prior authorization. CIGNA is also removing 500 procedures from the prior authorization list for Medicare Advantage.
The prior authorization process has long been criticized as administratively burdensome, delaying necessary care, and negatively impacting patient care. It has recently come into the crosshairs of Congress and CMS, who has indicated that it will release a final rule mandating insurers modernize their prior authorization process by December 2025 or sooner if possible (as reported by Politico). CIGNA, in particular, has been under scrutiny with a ProPublica investigative report on its prior authorization practices and a lawsuit accusing the insurer of using an algorithm to deny claims.
OTHER NEWS, IN BRIEF
Medicare Prescription Payment Plan Guidance Open for Comments. This is the first part of a two-part guidance implementing a provision in the Inflation Reduction Act (IRA) designed to reduce the burden of out-of-pocket prescription costs for Part D beneficiaries. CMS seeks to build the infrastructure to implement the program, allowing Medicare beneficiaries to pay for out-of-pocket prescription drug coverage costs in monthly payments over a year. Comments are due by September 20, 2023. A second round of guidance is scheduled to be released in early 2024, and the program will begin in 2025.
Advanced Research Projects Agency for Health (ARPA-H) Funding Announcement. ARPA-H announced its first funding effort, a $24 million project by Emory University to build messenger RNA platforms to target “cancer and other diseases.” This project is funded through ARPA-H's Open Broad Agency Announcement (BAA), which funds ideas for health research breakthroughs or technological advancements. The application is open until March 2024, and future funding will be awarded on a rolling basis. While the Administration has positioned this as part of its ongoing effort to eradicate cancer through the Cancer Moonshot initiative, STAT News explored in a recent article how messenger RNAs are an area where the drug industry has already spent time and considerable resources.
Telehealth Certification. The American Heart Association (AHA) has established the Certified Professional by the American Heart Association (CPAHA) -- Telehealth is open to all licensed healthcare professionals. The certification intends to show that the individual is following AHA requirements and their commitment to telehealth. AHA has said that the benefits include standardizing the training and delivery of telehealth services. Other organizations offer telehealth certification in specialty areas such as mental health, nursing, or general telemedicine services.
OPPORTUNITIES TO ENGAGE
2023 Burden Reduction Conference, November 15. Registration is now open for the Optimizing Healthcare Delivery to Improve Patient Lives virtual conference, which the CMS sponsors. Leaders from the government, healthcare organizations, and patient advocacy groups are encouraged to attend the meeting, focusing on reducing administrative burden and strengthening quality across the healthcare system.
ARTICLES THAT GRABBED OUR ATTENTION
This week, these articles grabbed our attention; we thought they would also interest you.
Turning CMS into a Health Technology Assessment Organization (New England Journal of Medicine; August 19, 2023)
Reducing Health Care’s Climate Impact — Mission Critical or Extra Credit? (New England Journal of Medicine; August 17, 2023)
Doctors, Patients Try to Shame Insurers Online to Reverse Authorization Denials (KFF News; August 22, 2023)
Medical Illustrations Neglect People with Dark Skin. A Nigerian Doctor-to-Be is Working to Change That (STAT News; August 22, 2023)
__________________
Would you like to receive this update directly in your inbox? Subscribe below to receive email updates like this and other timely content. Or you can contact me directly at smadhani@madhani-health.com.
__________________
For more information and questions, please contact:
Sheila Madhani, MA, MPH
Madhani Healthcare Consulting, LLC
Email: smadhani@madhani-health.com
www.madhani-health.com
Tel: (202) 679-2977