Health care’s fraud and abuse laws are getting overhauled

https://www.axios.com/health-care-fraud-abuse-stark-law-antikickback-changes-fd354212-9583-44c7-85e4-86e4690cc56e.html

Doctors dressed in blue operate on a patient in a surgical suite.

The Trump administration is proposing to loosen regulations that prohibit doctors from steering patients insured by federal programs to facilities where they have a financial interest and that outlaw health care companies from offering bribes and kickbacks in exchange for patient referrals.

Why it matters: The industry has long clamored for an overhaul to these laws, which companies say obstruct their goals of providing “value-based care.” But critics worry the broad and vague changes could engender more fraud and abuse than there already is.

Driving the news: The Department of Health and Human Services would create new exemptions for the physician self-referral law and the federal anti-kickback statute — decades-old, complex laws that forbid payments that encourage unnecessary care and increase taxpayer costs.

  • Hospitals, doctors, nursing homes and other entities would be able to create “value-based arrangements,” and those deals could include exchanging bonuses or other types of “remuneration” without running afoul of referral laws.
  • For example, under these exemptions, a hospital could provide a nursing home with a behavioral health nurse for certain discharged patients, or a hospital could donate cybersecurity technology to a physician’s office.
  • Many exemptions already exist, including for organizations called “accountable care organizations” that try to keep a patient’s care within a narrow set of hospitals and doctors, but these changes would go much further.

Between the lines: The overarching concern is everyone’s definition of “value” is different. How will regulators know whether providers are acting in good faith to coordinate care, or if they are using “value-based care” as a cover to control patient referrals and enrich themselves?

A major exclusion: Pharmaceutical companies, medical device firms, labs and medical equipment makers are cut out from the changes because the federal government is afraid those companies would “misuse the proposed safe harbors.”

  • Pharma lobbyists, in particular, have pushed hard to change the law so drug companies could directly subsidize drug copays for Medicare and Medicaid patients, even though federal officials have said that practice “masks the high prices those companies charge for their drugs.”
  • HHS Secretary Alex Azar told reporters the government may consider separate regulations for value-based drug contracts, even though the evidence of those deals’ effectiveness is limited at best.

The bottom line: These changes come at the same time that hospitals, physicians, pharmaceutical companies and others are paying out billions of dollars every year in fraud settlements.

  • Public comments are due Dec. 31, and if this comment process is anything like the initial requests that asked for guidance, the industry will be heavily involved.

 

 

 

How seniors are being steered toward private Medicare plans

https://www.axios.com/medicare-advantage-tilting-scales-7db28dd2-25af-4283-b971-21a61fa59371.html

Illustration of a wheelchair on one side of a seesaw with a hand pressing down the other side.

Today is the final day when seniors and people with disabilities can sign up for Medicare plans for 2019, and consumer groups are concerned the Trump administration is steering people into privately run Medicare Advantage plans while giving short shrift to their limitations.

Between the lines: Medicare Advantage has been growing like gangbusters for years, and has garnered bipartisan support. But the Center for Medicare Advocacy says the Trump administration is tilting the scales by broadcasting information that “is incomplete and continues to promote certain options over others.”

The big picture: The government has talked up the benefits of Medicare Advantage plans in emails to prospective enrollees during the past several weeks, the New York Times recently reported. Enrollment is approaching 22 million people, and there are reasons for its popularity.

  • Many MA plans offer $0 premiums and extra perks that don’t exist in standard Medicare, like vision and hearing coverage and gym memberships. MA plans also cap enrollees’ out-of-pocket expenses.
  • Traditional Medicare, by contrast, has higher out-of-pocket costs that usually require people to buy supplemental medical policies, called Medigap plans, as well as separate drug plans.

Yes, but: Federal marketing materials rarely mention MA’s tradeoffs.

  • MA plans limit which doctors and hospitals people can see, and they require prior approval for certain procedures. Provider directories also are loaded with errors.
  • MA plans spend less on care, yet continue to cost taxpayers more than traditional Medicare. Coding is a major problem.
  • People who enroll in MA often can’t buy a Medigap plan if they later decide to switch to traditional Medicare. And others, especially retirees leaving their jobs, may not even realize their employers are enrolling them in Medicare Advantage.

Where it stands: The Affordable Care Act slashed payments to MA insurers, but other Obama administration policies bolstered the industry. And now the Trump administration is helping it even more.

  • Obama officials built the chassis for today’s bonus system, which has been lucrative for plans (and likely wasteful, according to federal auditors).
  • A bipartisan 2015 law that adjusted Medicare payments to doctors killed the most popular Medigap plans, starting in 2020 — a move experts say could indirectly drive more people to MA.
  • HHS championed MA in a new policy document this week, on the heels of positive marketing.

What we’re hearing: Wall Street is beyond bullish on the major MA insurers like UnitedHealth Group and Humana. Supporters of MA like the idea of treating Medicare more like a marketplace, where people have to shop for a plan every year, but experts are worried about how it will affect the average enrollee.

“We know people don’t” actively engage in health insurance shopping, said Tricia Neuman, a Medicare expert at the Kaiser Family Foundation who recently wrote about MA. “It’s just too hard.”