CMS Rebuffed, Soda Tax, Bundled Payments, and more...

CMS’s Site-Neutrality Rule Struck Down

A U.S. District Court has invalidated a Centers for Medicare and Medicaid Services (CMS) regulation issued last November that treated payments made to hospital outpatient departments the same as those made to physician offices.
CMS’s final outpatient prospective payment system rule (OPPS) issued in November 2018 instituted the “site-neutral” payment policy for physician services. CMS argued that Medicare payments for such provider-based departments (PBDs) – for example, oncology clinics, urgent care clinics, or medical offices offering specialized care – should be paid the same relatively lower rate as care provided in a doctor’s office.
The American Hospital Association brought suit, arguing that PBDs have higher costs because they deliver more functions than standalone M.D. offices; they have to satisfy more stringent Medicare licensing and operation requirements similar to those that hospitals must follow; and that outpatient clinics usually serve sicker and poorer patients than physician offices. Hospitals also argued that more and more care is moving from inpatient settings to outpatient (in part to reduce overall healthcare costs), but that the outpatient care is still integrated with the entire hospital complex (which, nonetheless, has costs and overhead).
But aside from the caregiving and payment arguments, AHA argued that CMS exceeded its rulemaking authority, which is the factor on which the U.S. District Court based its opinion.

Full Implementation of MassHealth Claim Denials to Begin

The state informed the provider community last week that MassHealth will begin denying certain claims that lack the national provider identifier (NPI) for caregivers. The NPI designation is required under the Affordable Care Act for those providers that are ordering, referring, and prescribing. MassHealth has had an extended transition period to allow providers to get up to speed on the new requirement, but as of December 15, 2019, denials will occur for certain cases. Full implementation of the policy is expected to take place by November 15, 2020, including the requirement that all ordering, referring, and prescribing providers be actively enrolled in the MassHealth program.

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McGovern & Clark Ask: Where’s the Drug Report?

It’s an issue with which hospitals and physicians are far too familiar – the increasing shortages of drugs. Recent shortages have included such relatively common drugs such as epinephrine, lidocaine, and ketamine, as well as shortages of relatively newer drugs. The Food and Drug Administration convened an interagency Drug Shortages Task Force, held public hearing in September and October 2018, and kept the public docket on the issue open through January 2019 to gather input. Since then nothing much has happened.
Last week, a bipartisan Congressional letter, including signatures from Massachusetts Democrats James McGovern and Katherine Clark, asked Interim FDA Commissioner Norman “Ned” Sharpless, M.D. when he expected the FDA to release its report to Congress. The FDA has not had a permanent chief since March 2019, when former Commissioner Scott Gottlieb announced his resignation.

Fighting Obesity Through a Sugary Soda Tax

The Coalition for Action on Obesity – of which MHA is a member – recognized National Obesity Care Week last Wednesday with a presentation at the State House and release of a white paper from the Network for Excellence in Health Innovation. 
The paper calls for re-energizing the national agenda on prevention and treatment through access to structured lifestyle interventions such as the Diabetes Prevention Program; support for appropriate use of obesity medications; and addressing stubborn societal attitudes regarding obesity. Major medical societies such as the American Medical Association have declared obesity to be a chronic, treatable disease.
Among the recommendations of the white paper was a call to address obesity through public health regulation and programming. MHA continues to advocate for legislation, such as HB2529/SB1709, An Act to Promote Healthy Alternatives to Sugary Drinks, sponsored by Rep. Kay Khan (D-Newton) and Sen. Jason Lewis (D-Winchester). That bill would implement a tiered-tax on non-alcoholic, sugar-sweetened beverages based upon the drink’s sugar content. Proceeds from the tax would help fund a variety of community health initiatives. The healthcare community, alarmed by the rapidly increasing rates of diabetes and obesity, and armed with numerous studies proving the link between those health problems and sugary drinks, is a strong advocate for the tax.

Efficient Cancer Care? Yes. Forced, Problematic Rule? No

A new cost-cutting bundled payment methodology? Good. Directing that model toward 17 different kinds of cancer care for the benefit of patients? Good. But turning upside down the way such payment tests have been constructed in the past – that is, mandating participation rather than seeking a voluntary group of hospitals to test the risky venture – that’s very bad indeed.
CMS has issued a proposed rule that includes a radiation oncology (RO) model to test whether prospective, bundled payments for 90-day radiotherapy episodes of care would reduce Medicare spending while preserving or improving care. The problem isn’t with the model, bundled payments or accountable streamlined care – all things in which hospitals are participating every day. The problem arises from the fact that the model would carry high risk and be mandatory for physician group practices, hospital outpatient departments, and freestanding radiation therapy centers that deliver radiotherapy services for 17 types of cancer in certain areas of the country. (CMS will only reveal which parts of the country in its final rule.)
Because different hospitals of varying sizes are on different points along the path of transitioning to value-based care, the American Hospital Association (AHA) says a blanket rule should not be forced on all of them. Mandating that the program be up and operating on January 1, 2020 is impractical, AHA added.
Most disturbing is the risk-versus-reward of the proposal. “The AHA recognizes that, in crafting the proposed regulation, CMS attempted to achieve a balance between offering incentives for providers who achieve success and fulfilling CMS’s obligation to protect taxpayers and the Medicare Trust Fund,” the association wrote. “However, as proposed, the balance would be significantly misaligned and put the achievement of savings well out of reach for many providers. Specifically, the rule would require providers to take on 100% risk immediately upon starting in the model, without any stop-loss protections or adjustment for actual versus historical case mix.”

September 23: National Falls Prevention Day!

Today is National Falls Prevention Day, which is dedicated to raising awareness of the many practical ways falls are preventable and how risks can be reduced. The National Council on Aging has a wealth of information about falls, their costs to society, and the work now underway to prevent them.
In Massachusetts, hospitals have undertaken a host of interventions from providing footwear for elderly patients, to installing bed alarms, training staff, and much more. Massachusetts hospitals also track all falls and falls with injury and publicly report them to the state. You can see falls data for each unit of every hospital in Massachusetts, along with other resources to prevent falls, by visiting PatientCareLink.

Excellence in the Emergency Department

For many patients, the emergency department (ED) sets the tone for the entire patient experience. By implementing proven, evidence-based tools and techniques, leaders can create an ED where employees and physicians want to work and patients want to receive care. That's true whether an ED is big or small, inner city or rural, or in a teaching or community hospital. At this conference, we’ll hear from nationally recognized experts Dan Smith, M.D., and Stephanie Baker, R.N., from the Studer Group on leading practices from healthcare organizations that are doing things differently in the ED and seeing positive outcomes as a result. We’ll look at ways to tackle boarding, boost productivity, and optimize clinical documentation. And we’ll explore how to leverage leadership, improve training and development of clinicians and staff, as well as strengthen systems and processes, teamwork, agility and more. The conference is Friday, October 18, from 9 a.m. - 12:15 p.m. at the MHA Conference Center, Burlington, Mass.  Click here for more details and registration info.

John LoDico, Editor