MHA's Executive Briefing

AHA urges Congress to focus on ‘real reform,’ not further post-acute cuts

In a statement submitted June 13 to the House Ways and Means Health Subcommittee, the Ameican Hospital Association expressed deep concern with certain budget and regulatory proposals that would further reduce Medicare payments for long-term care hospitals, inpatient rehabilitation facilities, skilled nursing facilities and home health providers. Submitted for a hearing on the issue, the statement opposes the president’s fiscal year 2014 budget proposals for an additional market basket reduction for all post-acute care providers, a return to the 75% Rule for IRFs, and site-neutral payments for certain IRF and SNF procedures.

It also expresses deep concern with the Centers for Medicare & Medicaid Services’ FY 2014 proposal to allow the 25% Rule for LTCHs to expire; CMS research on a policy that would shift a majority of LTCH cases to the inpatient prospective payment system; and Medicare Payment Advisory Commission research on reform approaches that would eliminate the LTCH PPS. “The AHA believes we need real reform, not the further ratcheting of post-acute care provider payments as outlined in the president’s budget proposal, and by CMS and MedPAC,” the statement adds, and includes a bipartisan list of alternatives to cutting payments for hospital services.

Hospitals Lagging on PSO Contracts

A brief and little-known provision in the health reform law says any hospital with more than 50 beds will be shut out of the 2015 health insurance exchange plan offerings if it doesn't have a contract with one of 77 federally approved patient safety organizations. Few have these contracts now.

Read more here.

Meaningful use payment adjustments are coming soon, says CMS

2015 may still seem like it's far away, but healthcare providers know there's much to be done in the next two years. For eligible providers and hospitals that haven't made meaningful use a priority yet, 2015 might bring a 2% cut in Medicare reimbursements due to payment adjustments built in to the EHR Incentive Programs.

EHRintelligence spoke with Robert Anthony, Deputy Director of the HIT Initiatives Group, Office of E-Health Standards and Services at CMS to discuss the upcoming adjustments and what providers should know about what will happen in 2015.

ACA still missing key regulatory details

Some key regulatory details remain unanswered in the final months before the Patient Protection and Affordable Care Act's major provisions launch. Obama administration officials have insisted that they have issued all of the major regulations for the 2010 healthcare overhaul and are now focused on implementing the law's central pillars—state health insurance exchanges and expanded Medicaid coverage—later this year. But health policy experts said they still expect important regulations implementing provisions of the law, plus a large amount of so-called subregulatory guidance.   

Read more from Richard Daly in Modern Healthcare here.

HHS issues payment rate changes to the ACA's temporary "high-risk" plan program

On May 17, the Department of Health and Human Services (HHS) released an interim final rule with comment period setting new payment rates for services delivered to individuals enrolled in the federally-administered Pre-Existing Condition Insurance Plan (PCIP) program effective June 15, 2013. The rule specifies that most covered services furnished to enrollees in the federally-administered PCIP program will be paid at 100 percent of Medicare payment rates or, where Medicare payment rates cannot be implemented by the federally-administered PCIP, 50 percent of billed charges or a rate using a relative value scale.

Furthermore, in most circumstances, the rule prohibits facilities and providers from “balance billing,” or charging the enrollee an amount greater than the enrollee’s cost-sharing amount as calculated by the plan. While the American Hospital Association supports providing access to health care coverage for uninsured individuals with pre-existing conditions, they are concerned about HHS setting mandatory Medicare rates for most services provided to these enrollees.

Highlights of the interim final rule follow.

Background

The Patient Protection and Affordable Care Act (ACA) established a temporary high-risk insurance program to provide health insurance coverage to eligible uninsured individuals with pre-existing conditions. The program took effect June 21, 2010 and will end Jan. 1, 2014 when other ACA health coverage provisions begin, including new qualified health plans offered through the health insurance exchanges.

The ACA directed HHS to establish, directly or through contracts with states or nonprofit entities, the high-risk pool program. HHS contracted with some states to administer a high-risk pool using PCIP funds, known as “state-based PCIPs;” HHS administers a high-risk pool in the remaining states and the District of Columbia, known as “federally-administered PCIPs.”

Funding for the risk pool was set in statute at $5 billion. Since its inception, approximately 135,000 individuals have accessed the plan.

Interim Final Rule

The interim final rule applies only to the federally-administered PCIP.

Insufficient Funds. HHS states that the overall cost of the PCIP program is higher than originally projected and funding will expire unless the department implements policy changes. The ACA requires the HHS Secretary to make adjustments to eliminate any projected deficit. Over the past two years, the administration has implemented a number of provisions to contain costs with the intent of sustaining the program. In addition, on Feb. 15 the federally-administered PCIP suspended its acceptance of new enrollment applications.

New Payment Rate. Most services delivered to enrollees in the federally-administered PCIP program will be paid at: (1) 100 percent of Medicare payment rates, or (2) where Medicare payment rates cannot be implemented by the federally-administered PCIP, 50 percent of billed charges or a rate generated pricing methodology using a relative value scale. Excluded services are: prescription drugs, organ/tissue transplant, dialysis and durable medical equipment benefits. These new rates are effective June 15. The rates will become the new plan allowance for the covered service. The plan will reimburse the facility or provider for a portion of the rate, and the enrollee will be responsible for reimbursing the facility or provider for the remainder, based on current cost sharing rules.

Premiums and Cost-sharing. Also beginning June 15, in most circumstances, the rule prohibits any facility or provider from billing the enrollee an amount greater than the enrollee’s out-of-pocket cost for the covered service as calculated by the plan. In other words, providers will not be able to use “balance billing;” they may not bill a patient for the difference between the plan allowance for a covered service and the amount that the facility would otherwise charge for the service.

Exceptions to this provision are prescription drugs, organ/tissue transplant, dialysis and durable medical equipment benefits.

As a result of the interim final rule, facilities and providers have a choice – continue to treat federally-administered PCIP enrollees and accept the new payment rates, or choose not to provide care for federally-administered PCIP enrollees.

Next Steps

This interim final rule with comment period takes effect June 15. Comments will be accepted until July 19.

HHS urged to permanently extend protections for health IT donations

The American Hospital Association on May 13 voiced support for extending federal self-referral (or Stark) and antikickback protections for hospitals that want to help physicians adopt health information technology, but urged the Department of Health and Human Services to make the regulatory protections permanent. “We believe that they will continue for the foreseeable future to be of critical importance to the nation’s efforts to adopt and expand operation of a robust national health IT infrastructure,” AHA said in identical comments submitted to HHS’ Office of Inspector General and Centers for Medicare & Medicaid Services.

Their proposed rules would extend the protections, set to expire at the end of this year, through 2016. Among other recommendations, AHA said the final rule should continue to explicitly include all hospitals and health systems within the scope of donors protected by the regulations; remove a confusing statement about covered technology from the rule’s preamble; and avoid adding unnecessary complexity and administrative burden to the existing regulatory requirements.

Bill would delay ACA DSH cuts until FY 2016

Rep. John Lewis (D-GA) on May 9 introduced the DSH Reduction Relief Act (H.R. 1920), American Hospital Association-supported legislation that would delay for two years cuts to the Medicare and Medicaid Disproportionate Share Hospital programs under the Patient Protection and Affordable Care Act.

“The [ACA] contains reductions to the DSH programs based on the assumption that many of the uninsured and underinsured would receive coverage under the law,” said AHA Executive Vice President Rick Pollack. “However, the Supreme Court’s decision that the federal government could not compel states to expand their Medicaid programs has negatively impacted projected health insurance coverage. The DSH Reduction Relief Act of 2013 will help hospitals and the patients they serve by delaying the Medicaid and Medicare DSH funding cuts for two years. This will allow for coverage expansions to be more fully realized.”

Healthcare leaders expect big shift toward outpatient care

As the care delivery models of hospitals and health systems evolve, health care executives and materials and practice area managers predict a major shift in admissions from inpatient to outpatient settings. According to Premier healthcare alliance's spring 2013 Economic Outlook, 69% of the survey participants predict that outpatient volume will rise in 2013, as compared to last year's volume. And as outpatient admissions are projected to increase, nearly 24% of respondents suggest that inpatient volume this year will drop.

Read more from Modern Healthcare here.

19 metrics to measure hospitals' progress toward value-based care

Hospitals and health systems need metrics to determine their progress in moving toward a pay-for-performance model, according to a report by the American Hospital Association's Health Research & Educational Trust and Hospitals in Pursuit of Excellence. The report, Metrics for the Second Curve of Health Care, suggests metrics to meet four value-based strategies prioritized in a previously released AHA report, "Hospitals and Care Systems of the Future," as health care transitions from fee-for-service to pay-for-performance.

Read more from Becker's Hospital Review here.

GOP Lawmakers Call for Reboot of Meaningful Use Program

On April 16, six Republican senators released a 28-page white paper -- titled, "REBOOT: Re-examining the Strategies Needed to Successfully Adopt Health IT" -- outlining their concerns about current federal health IT policy, FierceEMR reports.   Read more from iHealthBeat here.