Category Archives: Health Policy

Can the F.T.C. Spur Healthcare Reform?

Posted on by • Posted in Antitrust, Competition, Federal Trade Commission (FTC), Health Policy, Healthcare Reform, Market Consolidation, Market Power, Market Share, Mergers & Acquisitions, Monopoly, Monopoly Behavior, Special Interest Groups • Leave a comment
Can the F.T.C. Spur Healthcare Reform?

“Follow the money,” was the advice of Deep Throat to the Watergate journalists. But now, new Federal Trade Commission Chair Lina Khan says that’s not enough when analyzing monopolies in both healthcare and rest of the economy. Follow the algorithms and follow the power, too, not just the money.

We all know how monopolies harm consumers with higher prices. But monopolies and powerful corporations cause harm in other ways. Some examples:

Not all of these examples are linked directly to potentially illegal anticompetitive activities. But all are linked to the exercise of insufficiently checked corporate power. Commissioner Khan has signaled that she will consider such harms when analyzing mergers and other potentially anticompetitive activities.

This expanded view of anticompetitive harm is a departure from Robert Bork’s more narrow approach to antitrust enforcement taken by the F.T.C. since publication of Bork’s 1978 book The Antitrust Paradox. Bork noted that in many cases, mergers resulted in economies of scale that lowered prices for consumers. By his standard, such mergers were permissible as benefiting the consumer.

But now Commissioner Khan – and others like-minded theorists called neo-Brandeisians – point to the other harmful effects beyond the seeming benefit of lower prices. For example, the flip-side of a monopoly’s position as seller is its monopsony as a purchaser of labor. If there is only one big potential employer, workers do not have a competitive labor market, depressing their bargaining power and wages. In the digital economy there is also potential jeopardy to data privacy and security, and coercion to use certain digital products. Think the teenage girls on Instagram.

Employees of a single powerful employer are also inhibited from rocking the boat with innovations, critiques, or whistleblowing. This enervates a truly competitive marketplace.

Commissioner Khan views the antitrust issue not as being one of bigness but rather of power, power that reduces true competition. Beyond merely looking at prices, she seeks to identify and quantify the other elements of power and competition.

This blog has implicated healthcare monopolies as one direct cause of relentless increases in spending. It has also embraced the view of Steven Brill that “over the last five decades a new ‘best and brightest’ meritocracy rigged not only healthcare, but also the entire American financial, legal, and political system to build ‘moats’ of protection to perpetuate their wealth and power.”

Commissioner Khan is now highlighting a key mechanism – anticompetitive political and financial power — by which healthcare corporations rig healthcare and by which other corporations have blocked reform in pursuit of short-sighted profits. She summarizes the remedy:

If you allow unfettered monopoly power to concentrate, its power can rival that of the state., right? And historically, the antitrust laws have a rich tradition and rich history, and a key goal was to ensure that our commercial sphere was characterized by the same types of checks and balances and protections against concentration of economic power that we had set up in our political and governance sphere. And so the desire to kind of check those types of concentrations of power, I think, is deep in the American tradition.

This blog thinks she is on the right track. Because healthcare reform is in the public interest and must be pursued even in the face of powerful special interests.

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Congress pitches bill to warn Medicare beneficiaries of late enrollment fees

Posted on by • Posted in Health Policy, Medicare, Medicare Late Enrollment Penalties, Medicare Part B, Medicare Part D • Leave a comment
https://www.beckerspayer.com/payer/congress-pitches-bill-to-warn-medicare-beneficiaries-of-late-enrollment-fees.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter

A bill introduced in Congress would require the government to warn adults 60 and older of penalties associated with late Medicare enrollment, according to a March 2 CNBC report. 

The move targets adults before they reach the Medicare-eligible age of 65, especially those who are not auto-enrolled in coverage through Social Security. The number of beneficiaries who must manually enroll in coverage at age 65 has increased 32 percentage points to 40 percent since 2008, according to CNBC. 

The bill specifically targets Medicare Part B, which hits enrollees with a penalty equal to 10 percent of the standard premium for each 12 months they should have been enrolled in. The penalties last a lifetime and adjust with premiums. 

Roughly 776,200 enrollees face penalties in 2020. Based on current premiums, monthly penalties would be about $46. 

Medicare Part D also has a penalty, but its rate is 1 percent of premiums paid, or about 33 cents based on current rates.

As America’s physician demographics shift, so do doctors’ priorities

Posted on by • Posted in American Medical Association (AMA), Health Insurance Coverage Adequacy, Health Policy, Healthcare Reform, Medicare for All, Physician • Leave a comment

https://mailchi.mp/7788648545f0/the-weekly-gist-february-25-2022?e=d1e747d2d8

 A recent New Yorker article details the history of the American Medical Association’s (AMA) opposition to single-payer healthcare, and the grassroots movement that nearly changed its position in 2019.

Since its founding in the 1840s, the largest association of the nation’s doctors has wielded significant influence over healthcare policy, and has been the most effective opponent of several waves of progressive healthcare reform proposals across the last century. More recent changes in the demographic makeup of its physician constituents have begun to mirror the US population. A quarter of today’s practicing physicians graduated from foreign medical schools, and gender and racial gaps in medical schools have been reduced. Today, half of medical students are female, and half are people of color.

The Gist: The perspectives, needs, and politics of the physician community are changing. Younger physicians tend to be more left-leaning, and more are employees, rather than entrepreneurial business owners. While physician pocketbook issues historically dominated the AMA’s policy positions, today’s younger physicians are increasingly motivated by social justice concerns, leading to advocacy positions that would have been unimaginable a few decades ago. 

Physician societies continue to move closer to endorsing more extensive healthcare reform policies, over trying to ensure economic protection for the profession—and in the long run, this shift in physician support could prove a key driver in increasing public approval of “Medicare for All” and other coverage reforms.

Hospitals avoid feared staff exodus after COVID vaccine mandate implementation

Posted on by • Posted in Coronavirus, Employee Mandate, Health Policy, Vaccination, Vaccine, Vaccine Booster, Vaccine Efficacy, Vaccine Safety • Leave a comment

https://mailchi.mp/7788648545f0/the-weekly-gist-february-25-2022?e=d1e747d2d8

The February 14th deadline for healthcare workers to receive their first dose of the COVID vaccine does not appear to have significantly worsened the hospital staffing crisis, even in rural hospitals. But the mandate hasn’t necessarily meant that all healthcare workers are now vaccinated, as some hospitals reported approving a flurry of medical and religious exemptions to avoid staff departures. 

The Gist: Just as when states and early-adopter health systems enforced healthcare worker vaccine mandates last year, COVID vaccine uptake jumped just ahead of the federal deadline. 

After months of challenges, we may finally be moving beyond debates over healthcare worker vaccine requirements. And as hospitalizations from the Omicron wave continue to decline, most states and health systems are not planning to implement booster requirements. 

Centers for Medicare and Medicaid Services (CMS) overhauls the Direct Contracting payment model

Posted on by • Posted in Accountable Care Organization (ACO), Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH), Center for Medicare and Medicaid Services (CMS), Direct Contracting, Health Policy, Medicare, Medicare Advantage • Leave a comment

https://mailchi.mp/7788648545f0/the-weekly-gist-february-25-2022?e=d1e747d2d8

On Thursday CMS announced it will replace all versions of its Global and Professional Direct Contracting (GPDC) model, which allowed primary care providers to take full or partial risk on managing cost of care for traditional Medicare beneficiaries, after progressive Democrats raised concerns about whether a growing presence of Medicare Advantage insurers and private equity-backed groups in the model might compromise patient care and access in the traditional Medicare program. GPDC will be replaced with a new three-year demonstration called Accountable Care Organization Realizing Equity, Access and Community Health (ACO REACH), to start enrollment in 2023. The 51 current participants in the GPDC model can move into ACO REACH as long as they meet new requirements, which include developing plans to identify and address health disparities, and ensuring providers control three quarters of governing boards (as compared to a quarter in the GPDC model). Private equity and insurer applicants can still apply, but must demonstrate a track record of direct patient care, delivering quality outcomes, and serving vulnerable populations.

The Gist: ACO REACH is largely a “re-skinning” of the Direct Contracting program, rather than a significant overhaul. Physician, health system, and ACO groups, who were concerned that the program would be canceled altogether, were pleased with the announced changes to the model, although debate continues on whether the new guardrails will effectively address concerns around for-profit insurer and investor participation.

Like Direct Contracting before it, ACO REACH will be an important vehicle for risk-ready providers to move more extensively into full-risk contracting, without launching a plan or partnering directly with a MA insurer. 

Ambulance rides are getting a lot more expensive

Posted on by • Posted in Ambulance, Health Insurance Coverage Adequacy, Health Policy, High Deductible Health Plans, High Prices, Out of Pocket Expenses, Surprise Bills • Leave a comment

https://www.axios.com/ambulance-rides-are-getting-a-lot-more-expensive-cee897fe-63b7-4412-aa67-718109773e79.html

The cost of an ambulance ride has soared over the past five years, according to a report from FAIR Health, shared first with Axios.

Why it matters: Patients typically have little ability to choose their ambulance provider, and often find themselves on the hook for hundreds, if not thousands of dollars.

The details: Most ambulance trips billed insurers for “advanced life support,” according to FAIR Health’s analysis.

  • Private insurers’ average payment for those rides jumped by 56% between 2017 and 2020 — from $486 to $758.
  • Ambulance operators’ sticker prices, before accounting for discounts negotiated with insurers, have risen 22% over the same period, and are now over $1,200.

Medicare, however, kept its payments in check: Its average reimbursement for advanced life support ambulance rides increased by just 5%, from $441 to $463.

Between the lines: Ambulances aren’t covered by the new law that bans most surprise medical bills, meaning patients are still on the hook in payment disputes between insurers and ambulance operators.

State of play: Ground ambulances are operated by local fire departments, private companies, hospitals and other providers and paid for in a variety of ways, which makes this a tricky issue to address, according to the Commonwealth Fund.

  • Some states — such as Colorado, Delaware, Florida, Illinois, Maine, Maryland, New York, Ohio, Vermont and West Virginia — have protections against surprise ground ambulance billing, a columnist in the Deseret News pointed out earlier this year.
  • But in California, Florida, Colorado, Texas, Illinois, Washington state and Wisconsin, more than two-thirds of emergency ambulance rides included an out-of-network charge for ambulance-related services that posed a surprise bill risk in 2018, according to a Peterson-KFF Health System Tracker brief.
  • The Biden administration has said it’s working on the problem.

The bottom line: Costs for ground ambulance care are on the rise and, with few balance billing protections, that means patients could still be hit with some big surprises if they wind up needing a ride in an ambulance.

House Republicans press HHS to end COVID-19 emergency, but hospitals want extension

Posted on by • Posted in American Hospital Association (AHA), Center for Medicare and Medicaid Services (CMS), Coronavirus, Dept of Health and Human Services (HHS), Federation of American Hospitals, Health Policy, Health System, Hospital, Hospital Industry, Pandemic, Public Health Emergency (PHE) • Leave a comment
https://www.fiercehealthcare.com/providers/house-republicans-press-hhs-end-covid-19-emergency-hospitals-want-extension?utm_source=email&utm_medium=email&utm_campaign=HC-NL-FierceHealthcareWeekly&oly_enc_id=8564C4000334E5C

House Republicans are demanding the Biden administration starts winding down the COVID-19 public health emergency, while hospital lobbying groups are pressing it to do the opposite.

A group of more than 70 House Republicans wrote Thursday to Department of Health and Human Services (HHS) Secretary Xavier Becerra asking to start the process to wind down the COVID-19 public health emergency (PHE), which was recently extended until April. At the same time, several hospital advocacy groups are hoping the agency keeps the PHE beyond this spring and wants a 60-day notice as to when it will end.

“Although the PHE was certainly necessary at the outset of the pandemic, it was always meant to be temporary,” according to the GOP letter led by Rep. Cathy McMorris Rodgers, R-Washington, ranking member of the House Energy and Commerce Committee.

Republicans want HHS to release a concrete timeline for when the agency plans to exit the PHE.

“We recognize that the PHE cannot end overnight, and that certain actions must be taken to avoid significant disruption to patients and healthcare providers, including working with Congress to extend certain policies like maintaining access to telehealth services for our nation’s seniors,” the letter added.

The PHE granted major flexibilities for providers to get reimbursed by Medicare for telehealth, but those powers will go away after the PHE. It also gave flexibility on several reporting requirements and eased other regulatory burdens.

Another major issue is that states are going to be able to start eligibility redeterminations for Medicaid, which have been paused since the PHE went into effect in January 2020. State Medicaid directors are seeking a heads-up on when the emergency will go away, as states can start to disenroll ineligible beneficiaries after the PHE expires.

Republicans also want Becerra to cite any programs that should be made permanent, and they want “swift action” to lift all COVID-19 vaccine mandates.

The Supreme Court upheld the Biden administration’s healthcare worker vaccine mandate, overturning a lower court’s stay that affected half of the country. The Centers for Medicare & Medicaid Services has deadlines for states to comply with the vaccination mandate, and facilities that don’t fully comply could risk losing participation in Medicare and Medicaid.

The Republicans charge that the mandates have not “stopped the spread of COVID-19 but have alienated many Americans and have caused staff shortages at hospitals and other healthcare facilities.”

Key drivers of the staff shortages, however, have been a massive surge of the virus overwhelming facilities caused by the omicron variant along with increased expenses facilities have faced for temporary nursing staff. Those lingering expenses are the reason hospital groups are pressing for HHS to do the opposite and extend the PHE beyond April.

The Federation of American Hospitals (FAH) also wrote to Becerra Thursday (PDF) seeking to continue to extend the PHE “well beyond its current expiration date in April 2022.” Even though the omicron surge appears to be easing, the virus is still creating major operational challenges for providers, FAH said.

It also wants the administration to give hospitals a 60-day heads-up when it plans to end the PHE.

“Unwinding the complex web of PHE waiver-authorized operations, programs and procedures—which will have been in place and relied on for more than two years—is a major undertaking that, if rushed, risks destabilizing fragile healthcare networks that patients rely on for care,” the letter said.

The American Hospital Association also wrote to congressional leaders Tuesday seeking for more relief from Congress to help systems overcome staffing shortages that have exacerbated due to the omicron surge.

“The financial pressures hospitals and health systems faced at the beginning of the public health emergency continue, with, for example, ongoing delays in non-emergent procedures, in addition to increased expenses for supplies, medicine, testing and protective equipment,” the letter said.

FAH President Chip Kahn told Fierce Healthcare on Friday that the issues Republicans address in the letter are different from the priorities of the FAH, namely that the association doesn’t focus on mask or vaccine mandates.

“What we are saying is that the PHE has many aspects to it, and so … we think [it] should be extended, but if you don’t then we need to have a lengthy or carefully thought through transition,” Kahn said.

He added that Becerra’s predecessor, acting Secretary Eric Hargan, told providers that they would get a 60-day notice before the end of the PHE. That deadline for such a 60-day notice is Feb. 15.

Kahn said he understands the administration may be under political pressure to end the emergency, but prior notice is absolutely needed.

“I don’t know how they will respond but if they do choose to pull out, we just want to make sure that it doesn’t leave anything behind,” he said.

MA payers cutting premiums to attract enrollees

Posted on by • Posted in Competition, Health Insurance Coverage Adequacy, Health Insurance Industry, Health Policy, Medicare, Medicare Advantage • Leave a comment
https://us17.campaign-archive.com/?e=d1e747d2d8&u=526c5e99ee0439b6f83f7c051&id=6da6d4f543

Last week, we examined how the fast-growing Medicare Advantage (MA) market remains heavily concentrated among a handful of large carriers. But amid this concentration, consumers have more options than ever before, both in terms of carriers and plans, as shown in the graphic below. 

The average MA enrollee can now choose from among 39 health plans offered by nine different payers, the majority of which feature $0 insurance premiums. An increasing number of plans also now offer a variety of non-medical benefits. 

Landing an MA consumer soon after they become eligible is critical for carriers, as more than seven in 10 Medicare beneficiaries stick with the plan they have year after year. While this “stickiness” may suggest enrollees are satisfied with their current coverage, it also calls into question whether the MA marketplace is actually working as intended. 

With another revenue boost to MA plans proposed for 2023, competition between plans—as well as consolidation among carriers—will continue to heat up, especially as the number of Medicare-eligible Americans will increase by nearly 50 percent over the next three decades.

Why Medicare’s Value-Based Payment Models aren’t working

Posted on by • Posted in ACA, Alternative Payment Model, Health Policy, Medicare, Medicare Advantage, Medicare Alternative Payment Models, Value-Based Healthcare • Leave a comment
CMS' Value-Based Programs | CMS

 A commentary piece in Health Affairs argues that CMS’s value-based payment (VBP) initiatives have not reached their full potential because they fail to take into account conflicting market dynamics.

The authors argue that VBP models won’t take hold unless CMS both increases the “carrots”, or positive incentives, that market dominant providers receive to support true care transformation, and sharpens the “sticks” by requiring participation in accountable care organization (ACO) models, decreasing the attractiveness of fee-for-service (FFS) payments, and banning anti-competitive commercial deals that discourage steering referrals toward lower-cost providers. 

The Gist: To date, CMS’s VBP efforts have largely fallen short of their two primary objectives: transforming care at scale across the country, and generating meaningful savings for the federal government.

With more and more seniors choosing Medicare Advantage (MA) each year, the federal government clearly views MA as the primary vehicle to control Medicare cost growth in the future—although savings will ultimately hinge on CMS cutting payments to insurers in the future. 

Over time, continuing to foster the growth of MA may prove more successful than overcoming the myriad complications of FFS-based VBP programs.