- The Affordable Care Act exchanges will see more competition in 2019, according to a new Kaiser Family Foundation report, in a rebound from prior years.
- An average of four payers per state will participate in the ACA marketplace in 2019, an increase from 3.5 in 2018. Less than one-fifth of enrollees will have one payer option, which is the lowest level since 2016. Despite those increases, the ACA exchanges’ market remains smaller than in the early days of the marketplace.
- Meanwhile, CMS announced on Wednesday that 804,556 people signed up for a plan through Healthcare.gov in the second week of open enrollment. Nearly 1.2 million Americans have signed up for health insurance so far. Enrollment is trending below the 2018 numbers.
Recent years have seen major payers drop out of the exchanges. However, more insurance companies are entering the marketplace and expanding their footprints for next year.
That’s despite Congress spiking the individual mandate penalty in 2019 and the Trump administration expanding low-cost offerings beyond the exchanges. The market stability is evident in the modest premium increases planned in most states in 2019. For the first time, ACA federal exchange premiums for the second-lowest cost silver plans are expected to decrease an average of 1.5%.
In its new report, Kaiser Family Foundation said the state average was five payers in the ACA marketplace in 2014, including only one in New Hampshire and West Virginia and 16 in New York. That average increased to six per state in 2015 before falling to 5.6 in 2016 and then 4.3 in 2017, as multiple payers left the marketplace because of losses and market instability. That average dropped even further to 3.5 in 2018. Slightly more than half of enrollees were limited to fewer than three payer options this year.
Despite concerns of more problems in 2018, ACA payers have actually found their footing — and are even enjoying profits now. Payers, such as Centene, Cigna, Oscar Health, Anthem and Wellmark are moving back into the market or expanding to more counties in 2019.
More than half of enrollees will once again have a choice of at least three payers in the exchanges in 2019.
There are still wide discrepancies though. Three states will have more than 10 payers and five will only have one option. Rural areas will again see fewer payers, KFF said.
For 2019, most payers will still practice silver loading. This practice lets insurance companies move costs associated with losing cost-sharing reduction (CSR) payments onto silver plans. Subsidies are tied to the cost of silver plans, which increases financial assistance to members. Silver loading means lower member costs.
Though consumers have more payer options in 2019, so far there has been little interest in open enrollment. Critics worry that 2019 will see even fewer people in the exchanges as Americans are no longer required to have health insurance.
CMS reported last week that only 371,676 people selected plans on Healthcare.gov during the first days of open enrollment. The second week saw enrollment numbers of more than 800,000 people. Of the roughly 1.2 million that have signed up so far, more than 270,000 are new enrollees.
- With its final Outpatient Prospective Payment System (OPPS) rule for 2019, CMS is eliminating the pay discrepancy Medicare beneficiaries face visiting a hospital-owned outpatient setting as opposed to a traditional doctor’s office. CMS said cutting reimbursement at hospital-owned outpatient settings for these visits will save Medicare $380 million in 2019 alone. The American Hospital Association promptly vowed to sue.
- On the 340B front, the agency is expanding payment cuts to off-site hospital departments in a bid to keep hospitals from shifting their pharmacy services to off-campus facilities. By doing this, hospitals receive higher payment rates, so CMS’ move is sure to anger safety net hospitals.
- The agency is also allowing Medicare beneficiaries to receive more care outside of hospitals by adding 12 additional procedures at ambulatory surgical centers, a move supplemented by reductions to reporting requirements for both ASCs and hospitals. Those reporting cuts are expected to save providers $27 million over the next two years, according to CMS.
As hospitals continue to gobble up competitors and physician practices, consolidation has had a perverse affect on where Medicare beneficiaries are getting low-acuity care and how much Medicare is paying for those services.
A 2015 GAO report found that after acquiring a physician practice, a shift occurred where more patients were seen at the higher-cost setting of a hospital outpatient facility rather than the lower-cost option of a traditional doctor’s office.
“While vertical consolidation has potential benefits, we found that the rise in vertical consolidation exacerbates a financial vulnerability in Medicare’s payment policy: Medicare pays different rates for the same service, depending on where the service is performed,” the GAO report found.
CMS’ final rule issued Friday is an attempt at creating “a level playing field” for providers, CMS administrator Seema Verma said in a statement.
The change is expected to save Medicare $380 million in 2019 alone, adding up to a sizable payment cut for hospitals.
Tom Nickels, Executive Vice President of the American Hospital Association (AHA) railed against CMS’ “ill-advised” payment cuts to outpatient clinics, arguing further that the rule is “based on unsupportable analyses and erroneous policy rationales” that will hit rural patients and vulnerable communities hardest.
Even so, the final rule eases up a bit compared to an earlier proposal, by spreading out the site-neutral cuts over two years.
And overall, factoring in the cuts and payment rate increases, reimbursement on a net basis will rise slightly, 0.6%, for nonprofit hospitals and 1% for for-profit, according to the final rule. Height analysts said that’s an improvement from the proposed rule in which nonprofits net reimbursement would have been negative.
Friday’s rule also would allow ambulatory surgical centers to do more, creating another threat to hospitals. Under the rule, ASCs could provide and be reimbursed for 12 additional procedures, mainly for cardiovascular issues, according to CMS.
The agency was expected to extend 340B payment cuts to previously exempt off-campus providers, a move proposed in July that received swift pushback from safety net hospital advocates and the hospital industry at large.
Maureen Testoni, interim president of advocacy group 340B Health, said in a statement that her organization is disappointed in the “misguided and damaging policy,” and encouraged Congress to move to reverse the cuts.
“Cutting Medicare payments for drugs for patients treated in 340B hospitals by nearly 30% will damage the healthcare safety net that serves uninsured, underinsured, and Medicaid patients across the country,” Testoni said. “We have already seen the negative impact these cuts are having on patient care. Our member hospitals report that they have had to cut back on services and have had to forgo hiring or lay off doctors, nurses, pharmacists, and other healthcare professionals.”
When CMS proposed extending 340B cuts to off-campus facilities in July, the American Hospital Association argued that the agency “misconstrued Congressional intent” to provide off-campus clinics with the existing outpatient payment rate. If CMS were to go through with the rule, AHA said at the time, it would ultimately “impede access to care for the most vulnerable patients” instead.
AHA, according to Nickels, intends to rally with other industry groups and “promptly bring a court challenge to the new rule’s site-neutral provisions.” AHA and a handful of other hospital associations are already in a legal battle with HHS over its 340B cuts.
BOSTON—For all the work involved in the Merit-based Incentive Payment System (MIPS), the highest-scoring physicians ended up with a 2.02% payment adjustment, leaving them disheartened with the program.
Doctors who scored the maximum 100 points under MIPS received only a 2.02% positive payment adjustment, said Drew Voytal, associate director for government affairs for the Medical Group Management Association (MGMA).
For many physicians, “It’s a wash,” Voytal told an audience at the MGMA’s annual conference in Boston on Monday. “They are feeling like it was just for nothing.”
Physicians and physician practices had to report quality and other data to achieve high scores in the MIPS program, often investing in additional resources from personnel to technology.
The problem? In the first year of the program, CMS made reporting easier in its “transition year.” The program is supposed to be budget neutral so that doctors and practices that incur penalties for failure to participate or poor performance pay for the positive payment adjustments for those who score well. In 2017, the first year of the program, CMS estimated that 91% of eligible physicians participated in the payment program. That kept them from avoiding a penalty that would have resulted in a 4% cut in their Medicare reimbursement—money that would have funded incentive payments to others.
When all was said and done and the Centers for Medicare & Medicaid Services (CMS) released the 2017 final scores for physicians who participated in the Medicare payment program—payments that will be made in 2019—many were disappointed.
“Many people are just disheartened,” Voytal said.
Voytal urged physicians to log into CMS’ Quality Payment Program website to review their scores. In fact, CMS recently discovered it made mistakes calculating MIPS payments to some physicians and revised many scores. Physicians and practices who believe errors were made in their scores now have until Oct. 15 to request a targeted review by CMS.
MGMA officials said CMS’ feedback to physicians was also not sufficient and for some was inaccurate.
To stay on track with MIPS, physicians should take the following steps moving forward, Voytal recommended:
- Assess your performance under past reporting programs to compare with how you are doing under MIPS.
- Evaluate your vendor readiness and costs, including asking about the use of 2015 Edition Certified Electronic Health Record Technology, which CMS proposes to require next year.
- Protect your practice against a MIPS penalty, including by failing to participate in the program if required.
- Determine your 2018 MIPS goal and establish a reporting strategy for the data you are required to submit.
- Comply with deadlines, such as those for submitting quality and other data.
Analyze your data at year end to see how you are doing and where you can improve
CMS is currently reviewing more than 15,000 comments on a proposed rule issued in July that will outline changes for year three of the physician payment program implemented under MACRA.
CMS will issue a final rule this fall. One proposed change will allow doctors in small practices who don’t meet the existing threshold to participate in MIPS to opt in, allowing them to be eligible for bonus incentives.
- A new study by researchers at Kaiser Permanente Northern California adds weight to the argument for using medical scribes to reduce reporting burden and physician burnout.
- Researchers analyzed use of scribes by 18 primary care doctors at two medical centers over a 12-month period in 2016 and 2017. The doctors were randomly assigned to use or not use scribes for the first three months and then alternated back and forth at three-month intervals for the duration of the study.
- During periods when scribes were used, doctors reported less after-hours EHR documentation (under an hour during the week and on weekends). They also reported a significant uptick in time spent interacting with patients — 85% spent more than 75% of visits focused on patients, versus 13% when scribes were not used. Also, doctors were more likely to finish documenting the encounter by the end of the day.
The report comes as CMS has promised to work with providers to reduce reporting burden, which is seen as an increasing liability with the looming doctor shortage. Nearly two-thirds of U.S. physicians in a Medscape survey reported feeling burned out, depressed or both, and 33% said those feelings affected interactions with patients. Those with the highest rates of burnout were family physicians and internists.
Scribes, essentially human note-takers for doctors, are one possible answer to this problem.
At the same time, a number of companies are also leveraging voice recognition technologies to streamline dictation work. A recent Epic and Nuance Communications partnership aims to help doctors retrieve schedules and look up patient information via voice-activated EHRs. And Google is teaming with Stanford Medical to assess AI and voice recognition in generating EHRs, with a focus on physician note taking.
The latest study showed that patients came out ahead as well when scribes were used, with more than six in 10 saying scribes had a positive impact on their visit.
In a follow-up survey, 88% of PCPs said they liked their scribe experience and 65% said they would be willing to take on additional patients in exchange for a full-time scribe. Of the six who were not willing to expand their panels, four already exceeded the practice limit, according to the study. It was published online in JAMA Internal Medicine.
“Our results suggest that the use of scribes may be one strategy to mitigate the increasing EHR documentation burden among PCPs, who are at the highest risk of burnout among physicians,” the authors wrote. “Although scribes do not obviate the need for improving suboptimal EHR designs, they may help alleviate some of the deficiencies of currently implemented EHRs.”
As the Trump administration barrels forward on Medicaid work requirements, new studies show the policy could remove millions from the program if implemented across the country.
In two recent studies highlighted by JAMA Internal Medicine, researchers found that, if implemented nationally, work requirements as written would not save a significant amount of money. But if those requirements throw more people off Medicaid than intended, which researchers find likely, savings could be higher.
Most of the Medicaid population is either already working or would be exempt from work requirements due to disability. Because those groups would retain coverage, one study found that only 2.8% of current enrollees should be at risk for disenrollment—a group that accounted for just 1%, or $3.8 million, of Medicaid spending last year.
Applied nationally, that 2.8% represents 2.1 million Medicaid beneficiaries.
And even that amount of savings could diminish if analysts accounted for the cost of implementing work requirements. Like drug testing requirements for food stamp recipients, the cost of administering such a policy could eat into—or erase—the savings generated by the policy.
“It’s not insignificant and it’s definitely possible that the cost of the implementation might exceed the savings, but that would only be if there’s no spillover effect and there probably will be,” lead author Anna Goldman, M.D., M.P.H., told FierceHealthcare.
That “spillover effect” is the rub. If proponents of work requirements seem more bullish on the idea than its initial outlook suggests, it could be because they are counting on spillover to take more people off Medicaid than are truly ineligible.
According to the letter of the law, people with disabilities are exempt from work requirements and those already working should be able to retain their Medicaid coverage. But at least some enrollees will be unable or fail to comply with documentation requirements in the new policy and will therefore lose Medicaid coverage for which they should have been eligible.
The precise amount of spillover is difficult to estimate, so while researchers noted its existence, they kept it out of their estimates. As a result, states could see increased savings from work requirements if the spillover effects prove large. However, in that case, “these savings would likely come at a substantial cost in terms of human health,” Goldman noted in the study.
“I think that in reality, it will save more money than we estimated, but we sort of wanted to estimate what the requirements would be if they followed the letter of the law,” Goldman told FierceHealthcare. “Either they’re not going to save any money or they’re going to throw a lot of people out that shouldn’t be thrown out. Those are the two possibilities here.”
Of those at risk of disenrollment, the average annual income is $3820, according to Goldman’s study and 42% are Black or Hispanic.
- As Hurricane Florence makes landfall, Charlotte, North Carolina-based Atrium Health and Winston-Salem-based Novant are readying plans to shift resources among their facilities to meet increased demand in areas hit hardest by the storm.
- As with last year’s Hurricanes Harvey and Irma, hospital operators in Florence’s path could take a financial hit. HCA, Tenet, Community Health Systems and LifePoint Health could all see volumes dip as patients and doctors are displaced by the storm and have to reschedule appointments and procedures. CNBC noted that LifePoint is particularly vulnerable with 30% of its beds in the Carolinas.
- As hospitals hunker down and prepare for the worst, American Well, Teladoc and other telehealth providers are offering free access to services to people who can’t access their usual providers due to the storm.
Telehealth companies played a major role during last year’s brutal hurricane season, assessing needs before, during and after each storm and adjusting offerings as needed to meet victims’ needs. The governors of Texas and Florida lifted restrictions on cross-border providers so that out-of-state doctors could provide care to people in the aftermath of Harvey and Irma.
Doctor On Demand said it will provide free medical virtual visits to anyone affected by Hurricane Florence through Sept. 30. The offer covers treatment of common conditions such as sprains, back pain, coughs and congestion, anxiety and depression, but does not cover psychology or psychiatry visits. MDLive also announced free telehealth consultations for storm victims.
Health information exchanges in the affected areas are also working to facilitate patient record sharing and ensure evacuees of Hurricane Florence continue to receive needed care.
“NC HealthConnex has been working for the last two days to allow exchange of health records across state lines to provide additional support to the provider who will be treating evacuees,” Executive Director Christie Burris told Healthcare Dive via email.
Tara Cramer, executive director of the Georgia Regional Academic Community Health Information Exchange (GRAChIE) , said the HIE is “currently taking connections live and … encouraging all partners to share lists of test patients available for exchanging testing and validation.”
On Thursday, CMS announced a slew of actions to help North Carolina and South Carolina respond to the storm. They include temporarily waiving certain Medicare, Medicaid and CHIP requirements, making special enrollment in federal health insurance exchange plans available to hurricane victims and activating an emergency response program for dialysis patients.
Additionally, CMS has made it easier for Medicare beneficiaries to replace medical equipment lost or damaged in the storm and directed Medicare Advantage groups and sponsors of Part D plans to maintain beneficiary access to covered benefits. The agency has also put together a disaster preparedness toolkit for state Medicaid agencies and said it is suspending surveys and enforcement activities for healthcare facilities in the two states.
“We are coordinating with federal and local officials to make sure that our beneficiaries, many of whom are some of America’s most vulnerable citizens, have access to the healthcare they need,” CMS Administrator Seema Verma said in a statement.
HCA saw its net income drop 31% to $426 million in the wake of last year’s devastating hurricanes, which ravaged southeastern Texas and much of Florida. Kindred Healthcare and Catholic Health Initiatives also suffered losses directly related to the storms.