Jul 29, 2024 | Uncategorized
The Centers for Medicare & Medicaid Services (CMS) has introduced new medical coding changes for Medicare, raising concerns among healthcare providers about the potential negative impact on patient care quality. To learn more about these proposed coding changes, continue reading. AMGA has requested that CMS not finalize the coding changes included in the 2024 Medicare Advantage Advance Notice, which would revise diagnoses and condition categories in the hierarchical condition categories (HCC) model. According to AMGA, the proposed changes to the risk adjustment model would negatively impact healthcare providers involved in value-based care contracts.
CMS has proposed transitioning from the ICD-9 coding system to ICD-10. While AMGA supports this shift, it has raised concerns about the revised HCC model, which includes fewer ICD-10-CM codes mapped to an HCC for payment purposes. Specifically, CMS has proposed removing over 2,000 unique codes from the HCC model that cover a variety of conditions, including depressive disorder, vascular disease, rheumatoid arthritis, and diabetes with chronic conditions. AMGA’s letter to CMS noted the limited timeframe for providers to review these changes, which could affect those in value-based contracts. Participation in value-based programs already presents challenges such as investing in analytics and hiring care managers. Adding more uncertainty could discourage provider participation.
Past changes to the risk adjustment model have been phased in, allowing plans and providers to adjust their systems and anticipate potential effects. If the proposals in the Advance Notice are finalized, Medicare Advantage plans must submit bids based on the new model by June 5, 2023, just four months after CMS released the proposal. AMGA urged CMS to extend the timeline for implementing the risk adjustment changes to allow adequate time for providers and plans to consider the effects and provide feedback. AMGA also expressed concerns about the minimal information CMS has provided to stakeholders and the unclear impact of the model changes.
Specifically, the proposed changes would standardize coefficient values for the diabetes group in the HCC model, regardless of complication status. This means that diabetes with severe acute complications, chronic complications, and unspecified or no complications will all have the same weight in the risk score, despite significant differences in care needs. CMS proposed a similar change for congestive heart failure. “By proposing to collapse these HCCs into a single risk score, CMS is discounting the importance of risk adjustment in the MA program,” the letter stated. “AMGA members in any value-based care arrangement, MA or otherwise, understand how critical accurate risk adjustment is for any population health-based model.”
AMGA said removing codes from the HCC model that represent conditions common among disadvantaged populations is “in stark contrast with CMS’ commitment to advance health equity throughout our public health system.” The changes will likely reduce payments to Medicare Advantage plans, impacting provider reimbursement and patient care access. AMGA suggested that CMS not finalize the proposed changes to the HCC model and instead work with stakeholders to help providers and plans understand the proposal’s effects.
While AMGA opposed the changes to the HCC model, the organization supported CMS’ proposal to align quality measures across Medicare. The Universal Foundation measurement is similar to an AMGA 2018 initiative that created a streamlined set of quality measures to simplify the reporting process and reduce provider burden.
AMGA is not the only provider group that has voiced opposition to the removal of diagnostic codes from the HCC model. America’s Physician Groups (APG) expressed similar concerns and called on CMS to delay the proposed modifications, explain its rationale for the specific coding changes, and acknowledge that the proposals could hinder health equity and value-based care advancements. APG also commissioned an ATI Advisory analysis which found that the changes would result in fewer patient visits that count toward risk adjustment. The share of visits contributing to risk adjustment would fall by one-third for patients with psychiatric conditions, 38 percent for those with musculoskeletal conditions, and 69 percent for patients with vascular conditions.
Original article published on revcycleintelligence.com
Jul 26, 2024 | Uncategorized
Due to the challenges physicians have faced in recent years, many are experiencing burnout and exhaustion. To address this, the American Medical Association (AMA) has developed a plan aimed at boosting morale. Continue reading to learn more about these developments.
The AMA has announced the AMA Recovery Plan for America’s Physicians to tackle the pressing challenges facing the nation’s doctors. Physician burnout was already a national concern before the coronavirus pandemic, and the pandemic has exacerbated this issue to crisis levels. The Association of American Medical Colleges projects a shortage of 37,800 to 124,000 physicians by 2034. AMA President Gerald Harmon, MD, emphasized the urgency of the situation, stating, “America’s doctors are a precious, irreplaceable resource. Physician shortages, already severe before COVID, have nearly become a public health emergency. If we don’t succeed with this Recovery Plan, attracting young talent to medicine and addressing the shortage will be even more difficult.”
The Recovery Plan focuses on five key areas:
- Supporting telehealth services, including insurance coverage
- Reforming Medicare payment for physician services
- Preventing “scope creep” that expands the practice scope of non-physicians, such as nurse practitioners
- Reforming prior authorization to reduce administrative burdens and avoid care delays
- Addressing physician burnout and reducing the stigma around mental health for physicians
Expanding Telehealth The pandemic led to unprecedented growth in telehealth, with 90% of physicians adopting it for patient care. Continuing telehealth services benefits both physicians and patients. Harmon noted, “The Centers for Medicare & Medicaid Services ensured that telehealth payment rates were equivalent to in-person services, even for audio-only visits. This has proven to be a viable option, offering safety, convenience, and time savings for patients. In rural areas, where geographic barriers pose significant travel challenges, digital health is invaluable.” Harmon stressed the importance of preserving telehealth advancements, saying, “Patients and physicians overwhelmingly support the continuation of telehealth post-pandemic. We are working to update laws and regulations to make this permanent.”
Reforming Medicare Physician Payment For years, Medicare reimbursement for physician services has been inadequate, creating financial uncertainty for physician practices. Harmon explained, “Medicare physician payments, the only healthcare delivery component subject to budget neutrality, have fallen 20% when adjusted for inflation since 2001. Legislative and regulatory changes during the COVID pandemic threatened a 10% cut in Medicare payments this past January. Thanks to the AMA and other medical organizations, Congress averted these cuts at the last minute—a major victory. However, we shouldn’t face this annual uncertainty. We need a permanent solution to ensure the economic viability of physician practices.”
Harmon underscored the need for payment reform, saying, “Predictable financial returns are essential for investing in costly infrastructure like new technologies and treatments. We are done with short-term fixes and looming cuts.”
Click here to continue reading
Jun 5, 2024 | Uncategorized
Summer is here, and many people are spending more time outside, swimming, and taking vacations. It is crucial to wear sunscreen to protect yourself from the sun. Read below for more information from the American Academy of Dermatology about the importance of sunscreen!
With Memorial Day marking the unofficial start of summer and the reopening of many beloved outdoor activities after the COVID-19 shutdown, it’s more important than ever to remember your sunscreen—especially after many of us spent months indoors. The American Academy of Dermatology (AAD) offers a great two-minute video and five tips for proper sun protection.
So get outside, enjoy your favorite activities, and don’t forget to apply that sunscreen. It’s finally summer! Click here to read more about sunscreen from the AAD.
May 29, 2024 | Uncategorized
Amazon In The Healthcare Space
The mere threat of Amazon.com Inc. entering the health care market has already started transforming U.S. health care, and not necessarily for the better. This looming presence has accelerated consolidation, leading to potential consumer disadvantages.
The speculation about Amazon’s involvement prompted two of the largest pharmacy benefit managers, CVS Health Corp. and Express Scripts Holding Co., to merge with major insurers, Aetna Inc. and Cigna Corp. These mergers consolidate more of the U.S. health care system under fewer companies. While the merging companies claim this will reduce costs for consumers and the nation, the reality is likely to be more complex and less favorable.
About The Mergers
These mergers were made possible partly due to the Federal Trade Commission and the Department of Justice blocking the mergers of Anthem Inc. with Cigna and Aetna with Humana Inc. These mega-insurers would have been too preoccupied with their own integrations to pursue such vertical deals and would have been too large to be acquired by other insurers.
UnitedHealth Group Inc. has also played a significant role in motivating these mergers. It pioneered aggressive diversification by acquiring a large PBM in 2015 and through its Optum health-services unit. Its success in patient enrollment, revenue growth, and market valuation has set a benchmark, inspiring similar strategies among its peers. Additionally, profit pressures on PBMs likely made them more open to merging with insurers.
However, Amazon’s potential entry into the health care market is a significant factor driving these deals. Amazon’s technological capabilities, long-term investment approach, vast appetite for new ventures, and tolerance for thin margins have unsettled investors, especially those involved in the industry’s middleman roles. If these mergers are finalized, the result will be unprecedented market concentration, with the three largest U.S. PBMs tied to three of the largest insurers.
Effects On Prescriptions
CVS, Express Scripts, and UnitedHealth currently process over 70% of all U.S. prescriptions. Post-merger, three companies will manage the insurance of over 90 million people, process more than 3.5 billion prescription claims, and generate over $500 billion in revenue. While not every American will have both their medical and drug benefits managed by the same company, many more will in the future.
These integrated companies will have more comprehensive information about their customers and a greater ability and incentive to manage total health spending. UnitedHealth is already deeply integrated, with investments in ambulatory surgery centers and physician groups. The merger of CVS and Aetna, which adds retail pharmacies and primary care clinics to the mix, could significantly impact patient lives.
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May 27, 2024 | Uncategorized
The American Medical Association (AMA) recently sent a letter to congressional leaders advocating for updates to the Medicare Physician Payment System. Following a Medicare Payment Advisory Commission (MedPAC) report, the AMA has urged Congress to implement a stable annual payment rate that aligns with inflation and practice costs.
The MedPAC report, presented to Congress on March 15, 2022, recommended maintaining the freeze on Medicare physician payment rates and not increasing them for 2023. The AMA has expressed significant concerns about this recommendation, emphasizing that it would negatively impact patient access to care as practice costs rise.
MedPAC’s report stated that despite the decline in Medicare service volume and revenue due to the pandemic, Congress provided substantial relief funds to clinicians. MedPAC expects these volumes and revenues to rebound to pre-pandemic levels by 2023. However, the AMA argues that financial challenges persist for physicians. They cite ongoing fiscal uncertainties related to the COVID-19 pandemic, statutory payment cuts, the consistent lack of inflationary updates, and significant administrative barriers as major issues affecting the stability of the Medicare physician payment system.
Inconsistency In Recommendation
The AMA also highlighted the inconsistency in MedPAC’s recommendation to freeze physician payment rates while CMS projects an 80 percent increase for Medicare Advantage plans in 2023. Data from the Medicare Trustees show that Medicare physician pay has increased by only 11 percent from 2001 to 2021, with one-third of that increase coming from a temporary 3.75 percent update set to expire this year. In contrast, Medicare hospital and skilled nursing facility payment rates have increased by over 60 percent during the same period. When adjusted for inflation, Medicare physician payment rates have declined by 20 percent over the past two decades, while the costs of running a medical practice have risen by 39 percent since 2001.
Additionally, Medicare physician fee schedule spending per enrollee has declined by 1 percent over the last ten years, while other Medicare benefits spending has significantly increased. For instance, Part B fee-for-service spending per enrollee, excluding physician fee schedule spending, rose by 42 percent over the last decade. Part A fee-for-service spending increased by 3.6 percent, Part C spending by 29.4 percent, and Part D spending by 20 percent.
Free Set To Continue Until 2026
The Medicare physician payment freeze is set to continue until 2026, after which payment updates will resume at a rate of 0.25 percent per year, far below the rate of medical or consumer price index inflation. The AMA warns that unless Congress updates Medicare physician payments to reflect inflation, the gap between payment rates and rising practice costs will continue to widen.
The AMA also referenced a May 2021 study that revealed the high costs of compliance with the Medicare Merit-Based Incentive Payment System (MIPS), amounting to around $12,800 and over 200 hours per physician annually. Furthermore, physicians have not been able to receive annual incentive payments for Medicare Advanced Alternative Payment Models (AAPM) due to the lack of transition opportunities.
The AMA stressed that financial hardships, burnout, and stress are driving many physicians to consider leaving their practice within two years. While expressing gratitude to Congress for the financial relief provided during the pandemic and for preventing a 10 percent physician payment cut in 2022, the AMA urged officials to collaborate with the physician community to develop solutions to the systemic issues plaguing the Medicare physician payment system.
Original article published on revcycleintelligence.com
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