Sheila Madhani Sheila Madhani

Weekly Roundup (July 31-August 4, 2023)

Physician payment, coding, coverage, and quality reporting news highlights.

Congress heads into summer recess this weekend, but there is still lots to keep health policy wonks occupied. As for last week’s vote on whether we should get rid of the honorific of “Dr.” in the medical setting, the results were 50/50, right down the middle. Have a good weekend!

PAYMENT

Stacking Up the Payment Rules. Now that the 2024 payment rules have arrived, we can see how the annual updates stack up. Annual updates only tell part of the story. For example, while the inpatient hospital payments are expected to experience a 3.1% increase, the Medicare agency is decreasing disproportionate share payments by $957 million. And some may argue that comparing different payment rules is an apples-to-oranges comparison.  Nevertheless, annual update percentages released by the Medicare agency are generally good barometers of the direction of payment rates and the intensity of changes (either up or down) in the coming year.

This chart illustrates that lacking an inflationary update or a statutorily required positive adjustment, the physician fee schedule is the only Medicare payment system to experience a negative adjustment in 2024. This will require Congressional action to reverse. Stakeholders have been urging Congress to address these cuts in the short term and to implement more fundamental changes to the system in the long term. Even with a 3.1% positive update, the American Hospital Association has called the 2024 update “woefully inadequate” to address rising costs.

PAYMENT INNOVATION

New Dementia Model Targeted at Care Coordination and Providing Support to Unpaid Caregivers. On July 31, 2023, the Centers for Medicare and Medicaid Services (CMS) announced the Guiding and Improved Dementia Experience (GUIDE) Model. GUIDE is a voluntary, nationwide model that advances President Biden’s Executive Order 14095 on Incentivizing Access to High Quality Care and Supporting Caregivers.

Model Overview

  • Timeline: The model will launch on July 1, 2024, and run for eight years. CMS is accepting letters of interest through September 15, 2023, and will release a Request for Applications in the coming fall.

  • Model Purpose: The agency estimates that in 2023 dementia affects 6.7 million Americans, and it is projected to increase to 14 million by 2060. The model intends to improve the quality of life for patients with dementia and their unpaid caregivers. The model is also designed to prevent or delay long-term nursing care as long as appropriately possible. The agency has also indicated that in developing the model, they have embedded elements to advance health equity by considering the CMS Innovation Center’s Strategy Refresh.

  • Model Participants: The model is open to Medicare Part B enrolled providers and suppliers, excluding Durable Medical Equipment and Laboratory Suppliers. Participants should have experience in dementia care and maintain an interdisciplinary team. There are two tracks for model participants: Established Program Track and the New Program Track for those not operating a comprehensive outpatient dementia care program.

  • Targeted Beneficiaries: Beneficiaries with dementia enrolled in Original Medicare Parts A and B will be placed in one of five tiers based on the progression of their dementia and their caregiver status (with or without a caregiver). Patients cannot reside in a long-term nursing home or enrolled in Medicare’s hospice program.

  • Payment Methodology: Model participants will receive a per beneficiary per month payment and can bill for respite care for certain patients. Certain safety net providers in the New Program Track will be eligible for a one-time, lump-sum infrastructure payment.

CMS scheduled a webinar for August 10 to provide an overview of the model.

CODING

2023 Naming Convention Framework Released by AHIMA. Initially published in 2022, the American Health Information Management Association (AHIMA) released an updated version. Naming policies provide standardization in the collection and documentation of patient information. These standards are necessary for maintaining interoperable systems and supporting patients' safety standards. Currently, naming practices are not standardized across healthcare systems. AHIMA, calling for adopting this framework, cites research on the administrative burden caused by a lack of standards. The Office of the National Coordinator recognized the 2022 version (Recommended Data Elements for Mater Patient Index) and is accepting public feedback on this document.

ICD-11 Implementation Benefits and Challenges Considered. While some of us are still recovering from the implementation of ICD-10, an article published this week in JAMA Health Forum considers the implementation of ICD-11, which became available globally on January 1, 2022. The authors highlight the benefits of this “more comprehensive, fully digital system” but caution that implementation and integration into current systems would require significant planning. In 2021, the National Committee on Vital and Health Statistics recommended to Secretary Becerra that research should be conducted on the impact of different approaches to the transition to ICD-11 and that the government should conduct regular outreach and communication with the U.S. healthcare industry. ICD-10 was implemented in Canada in 2000, but it was not implemented in the U.S. until 2015. Based on that experience, I would not recommend recycling your ICD-10 books yet!

August 7, CPT Editorial Panel Holds Virtual Meeting. Proprietary Laboratory Analysis (PLA) codes and COVID-19 vaccine revisions are on the agenda for this meeting. This meeting is being held in addition to the regularly scheduled September 2023 CPT Editorial Panel meeting, which is part of the 2025 CPT Book/Medicare Physician Fee Schedule cycle.

COVERAGE

Authors Consider the Legal Basis for CMS Authority for Coverage Decisions. In an article released this week in JAMA Internal Medicine, the authors review the authority used by the Medicare agency to make coverage decisions for products approved by the Food and Drug Administration. These decisions can significantly impact policy, the Medicare budget, and access to these products for individual Medicare beneficiaries. The authors note that CMS exercises significant legal discretion when making these decisions. In certain circumstances, CMS has limited coverage using tools such as Coverage with Evidence Development or limiting coverage for certain conditions. The authors conclude that in this current environment of limiting agency discretion through court challenges, Congress may wish to “reaffirm” CMS’s authority to make such decisions.

OTHER UPDATES, IN BRIEF

Surprise Billing. On August 3, CMS temporarily suspended the Federal Independent Resolution (IDR) process. The agency shut down the IDR portal because of a decision by a federal district judge in Texas who agreed with plaintiffs that IDR fee increases and rules on claims batching violated the Administration Procedures Act.

Payment Innovation. In a Health Affairs Blog, CMS leadership reiterates the value it sees in accountable care organizations and lays out its plans for their future. On July 27, 2023, 17 national stakeholder groups submitted a letter to Congress on the Value Healthcare Act of 2023, which includes provisions to reform alternative payment models (APMs), including extending the Advanced APM incentive bonus scheduled to expire at the end of the year.

COVID-19. On August 1, the Biden Administration launched the Office for Long COVID Research. The Office will be part of the Department of Health and Human Services. In the same announcement, the Administration noted the Long COVID clinical trials launched through the RECOVER Initiative.

Regulations and other documents.

 

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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 

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