Category Archives: Medicare Reimbursement

Medicare Advantage plans pay physicians less than original Medicare

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https://www.healthcarefinancenews.com/news/medicare-advantage-plans-pay-physicians-less-original-medicare

MA pays 10% to 15% less than what is paid by the government in original Medicare, report says.

A new study confirms what the American Medical Association and other medical groups have long been saying about physician pay: Medicare reimbursement is not keeping up with inflation.

In original Medicare, doctors are paid one-third less than a decade ago, the report said. Medicare reimbursement rates for outpatient procedures have decreased every year since 2016, for an overall decline of 10%.

Over the same period, inflation has risen by almost 30%, according to the report.

The report also sheds light on Medicare Advantage reimbursement. Medicare Advantage plans pay physicians an estimated 10% to 15% less than what is paid by the government in traditional Medicare, according to the 2025 Omniscient Health Physician Medicare Income Report. 

This can create negative margins for physicians considering MA plans take roughly twice as long to reimburse providers compared to original Medicare along with factoring in prior authorization and denials, the report said. 

An estimated 54% of Medicare beneficiaries are enrolled in a MA plan.

WHY THIS MATTERS

The MA reimbursement gap is driving shifts in network participation. A 2024 survey by the Healthcare Financial Management Association found that 19% of health systems have stopped accepting at least one MA plan, with another 61% planning to do so or actively considering it, according to the Omniscient report.

“Despite the rising demand for care from an aging U.S. population, the financial strain is forcing physicians to rethink whether they will continue serving Medicare patients,” said Meade Monger, CEO of Omniscient Health, a healthcare data science company. “High-volume Medicare practices, especially those in primary care and rural areas, are increasingly unable to sustain operations under current revenue structures.”

The federal government’s push toward streamlining and speeding up the prior authorization process and requiring an electronic process over paper represents improvement, the report said. Some insurers have announced plans to decrease the number of procedures that require prior auth.

But payment rates need to change, said Omniscient, which recommends policymakers index Medicare reimbursement rates to inflation and set payment standards for MA plans. 

THE LARGER TREND

On Tuesday, the American Medical Association released what it called flawed proposals in the Centers for Medicare and Medicaid Services’ physician payment rule released in July.

Despite getting a 3.6% payment boost after five consecutive years of cuts, physician pay, after adjusting for practice-cost inflation, has plummeted since 2001, the AMA said.

The proposed 2026 Medicare Physician Fee Schedule includes a 2.5% cut in work relative-value units (RVUs, which measure a physician’s time, technical skill, mental effort, decision-making and stress) and physician intraservice time for most services, the AMA said. This reduction would affect 95% of the services that doctors provide. 

The cut is based on an assumption of greater efficiency and less time involved for each service, an assumption that is not grounded in new data or physician input, the AMA said. 

CMS also proposes a reduction in practice-expense RVUs, which are the costs of running a practice, such as staff, equipment, supplies, utilities and overhead.

The bottom line, the AMA said, is that physician payment for services performed in a facility will drop overall by 7%.

CMS is accepting comments on its proposed rule until Sept. 12.

What Trump and the GOP have planned for healthcare

Posted on by • Posted in ACA, Congressional Budget Office (CBO), Health Insurance Coverage Adequacy, Health Insurance Denial, Health Insurance Industry, Health Policy, Health System, Healthcare Reform, Hospital, Hospital Industry, Medicaid, Medicaid Block Grants, Medicaid Eligibility, Medicaid Expansion, Medicaid Work Requirements, Medicare, Medicare 340B Drug Discount Program, Medicare Advantage, Medicare Cuts, Medicare Denials, Medicare Hospital Fund, Medicare Payment, Medicare Payment Advisory Commission (MedPAC), Medicare Reimbursement, Medicare Site Neutral Payment, Project 2025, State of the Union, Tax Exempt Debt, Tax Exempt Status • Leave a comment
https://www.healthcarefinancenews.com/news/what-trump-and-gop-have-planned-healthcare?leadId=1234536&mkt_tok=NDIwLVlOQS0yOTIAAAGYKMuOSDpr4HmVgwoir-sctcWYrTCmAMidk2ElOKJYQgYV2OewZexaTT7OGNmdoOgJX4esGPrurXZW_6oPMprQ0Mc5ph-PR7Pcrbc3LivGTNmd

Health systems are rightly concerned about Republican plans to cut Medicaid spending, end ACA subsidies and enact site neutral payments, says consultant Michael Abrams, managing partner of Numerof, a consulting firm.

“Health systems have reason to worry,” Abrams said shortly after President Donald Trump was inaugurated on Monday. 

While Trump mentioned little about healthcare in his inauguration speech, the GOP trifecta means spending cuts outlined in a one-page document released by Politico and another 50-pager could get a majority vote for passage.

Of the insurers, pharmaceutical manufacturers and health systems that Abrams consults with, healthcare systems are the ones that are most concerned, Abrams said.

At the top of the Republican list targeting $4 trillion in healthcare spending is eliminating an estimated $2.5 billion from Medicaid. 

“There’s no question Republicans will find savings in Medicaid,” Abrams said.

Medicaid has doubled its enrollment in the last couple of years due to extended benefits made possible by the Affordable Care Act, despite disenrolling 25 million people during the redetermination process at the end of the public health emergency, according to Abrams.

Upward of 44 million people, or 16.4% of the non-elderly U.S. population are covered by an Affordable Care Act initiative, including a record high of 24 million people in ACA health plans and another 21.3 million in Medicaid expansion enrollment, according to a KFF report. Medicaid expansion enrollment is 41% higher than in 2020.

The enhanced subsidies that expanded eligibility for Medicaid and doubled the number of enrollees are set to expire at the end of 2025 and Republicans are likely to let that happen, Abrams said. Eliminating enhanced federal payments to states that expanded Medicaid under the ACA are estimated to cut the program by $561 billion.

If enhanced subsidies end, the Congressional Budget Office has estimated that the number of people who will become uninsured will increase by 3.8 million each year between 2026 and 2034. 

The enhanced tax subsidies for the ACA are set to expire at the end of 2025. This could result in another 2.2 million people losing coverage in 2026, and 3.7 million in 2027, according to the CBO.

WHY THIS MATTERS

For hospitals, loss of health insurance coverage means an increase in sicker, uninsured patients visiting the emergency department and more uncompensated care.

“Health systems are nervous about people coming to them who are uninsured,” Abrams said. “There will be people disenrolled.”

The federal government allowed more people to be added to the Medicaid rolls during the public health emergency to help those who lost their jobs during the COVID-19 pandemic, Numerof said. Medicaid became an open-ended liability which the government wants to end now that the unemployment rate is around 4.2% and jobs are available.

An idea floating around Congress is the idea of converting Medicaid to a per capita cap and providing these funds to the states as a block grant, Abrams said. The cost of those programs would be borne 70% by the federal government and 30% by states.

This fixed amount based on a per person amount would save money over the current system of letting states report what they spent.

Another potential change under the new administration includes site neutral Medicare payments to hospitals for outpatient services.

The HFMA reported the site neutral policy as a concern in a list it published Monday of preliminary federal program cuts totaling more than $5 trillion over 10 years. The 50-page federal list is essentially a menu of options, the HFMA said, not an indication that programs will actually be targeted leading up to the March 14 deadline to pass legislation before federal funding expires.

Other financial concerns for hospitals based on that list include: the elimination of the tax exemption for nonprofit hospitals, bringing in up to $260 billion in estimated 10-year savings; and phasing out Medicare payments for bad debt, resulting in savings of up to $42 billion over a decade.

Healthcare systems are the ones most concerned over GOP spending cuts, according to Abrams. Pharmacy benefit managers and pharmaceutical manufacturers also remain on edge as to what might be coming at them next.

THE LARGER TREND

President Donald Trump mentioned little about healthcare during his inauguration speech on Monday.

Trump said the public health system does not deliver in times of disaster, referring to the hurricanes in North Carolina and other areas and to the fires in Los Angeles.

Trump also mentioned giving back pay to service members who objected to getting the COVID-19 vaccine.

He also talked about ending the chronic disease epidemic, without giving specifics.

“He didn’t really talk about healthcare even in the campaign,” Abrams said.

However, in his consulting work, Abrams said, “The common thread is the environment is changing quickly,” and that healthcare organizations need to do the same “in order to survive.”

CMS proposes a nearly 3% cut to Medicare physician pay for 2025

Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Medicare Physician Fee Schedule (MPFS), Medicare Reimbursement, Physician, Physician Reimbursement • Leave a comment

https://www.kaufmanhall.com/insights/blog/gist-weekly-july-12-2024

On Wednesday, the Centers for Medicare & Medicaid Services (CMS) issued its proposed annual changes to physician payments in its 2025 Medicare Physician Fee Schedule Proposed Rule. Required by statute to maintain budget neutrality, CMS is proposing to reduce the conversion factor—which translates the cost of providing medical services into physician payments—by 2.8%.

This is expected to lower physician payments by 2.93% on average. The proposed rule also includes new telehealth flexibilities, changes allowing eligible accountable care organizations access to a quarterly advance on their earned savings, and new payments for providers that help patients at high risk of overdose or suicide.

The Gist: With CMS proposing to reduce physician payments for the fifth straight year, the American Medical Association and other physician groups are once again calling on Congress to avert these cuts. 

Congress has previously responded with “Band-Aid” solutions to temporarily reduce or eliminate reductions for the next calendar year, but physician groups are demanding a more comprehensive fix that ties Medicare payment updates to the Medicare Economic Index, a measure of practice cost inflation. 

Medicare physician pay has declined 20% relative to practice costs from 2000 to 2021, and post-COVID inflation has only worsened the issue. Although lawmakers on Capitol Hill have explored various means of doing so, structural changes to Medicare budgetary policy face an uphill legislative battle in a presidential election year.

    Medicare Physician Payment Not Keeping Up

    Posted on by • Posted in Consumer Price Index (CPI), Inflation, Medicare Economic Index (MEI), Medicare Physician Fee Schedule (MPFS), Medicare Reimbursement, Operating Margin, Physician, Physician Compensation, Physician Practice Management, Physician Practice Margins • Leave a comment

    https://www.kaufmanhall.com/insights/infographic/medicare-physician-payment-not-keeping

    Following the US Senate Finance Committee’s recent white paper on Medicare physician payment reform, the graphic above shows how Medicare payments to physicians have not kept pace with inflation. 

    The Medicare physician fee schedule conversion factor, which is used to assign dollar amounts to relative value units, decreased by eight percent between 2000 and 2024. 

    Over the same period, the Medicare Economic Index (MEI), which measures practice cost inflation, and Consumer Price Index rose 57 percent and 83 percent, respectively. Reductions to the conversion factor contributed to a 20 percent decline in Medicare physician pay relative to practice cost inflation from 2000 to 2021. 

    Physician practice margins in general have also worsened since COVID, not just due to Medicare payments. 

    Although net revenue per physician at system-affiliated clinics increased about 10 percent from 2020 to 2023,total expenses per physician rose about 27 percent, driven by a per physician clinical staffing expense increase of nearly the same amount. 

    Both the Senate Finance Committee’s white paper and a recently introduced House bill suggest tying the Medicare physician fee schedule conversion factor updates to the MEI, either partially or fully, but immediate legislative action in an election year appears unlikely. 

    In the meantime, physician practices continue to face a difficult operating environment with costs rising faster than revenues.

    Hospital at home programs at a critical juncture

    Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Health System, Hospital, Hospital at Home, Hospital at Home (HaH), Hospital Industry, Medicare Reimbursement, Medicare Waiver • Leave a comment

    https://www.kaufmanhall.com/healthcare-consulting/gist-resources-kaufman-hall/kaufman-hall-blogs/gist-weekly

    Published in Health Affairs last month, this piece explores the history of hospital at home (HaH) programs and examines some of the barriers currently limiting their growth.

    HaH programs were introduced in the US back in the 1990s but remained rare due to a lack of reimbursement. That changed in 2020 when the Centers for Medicare and Medicaid Services (CMS) introduced the Acute Hospital Care at Home waiver, which allows fee-for-service Medicare reimbursement for providing inpatient-level care at home, prompting the number of HaH programs nationwide to swell from about 20 to more than 320 today.

    Although early findings from this initiative have been positive, the future of many of HaH programs is in doubt, as the waiver is set to expire at the end of 2024, barring congressional action.

    The authors argue that making the Medicare waiver program permanent is essential to overcome HaH’s “common agency problem,” which prevents many hospitals from building out their home-based programs to scale if they cannot receive reimbursement for all eligible patients. 
    The Gist: The Medicare waiver program has incubated many new HaH programs, but most of these programs remain very small; even for systems with the most robust programs, HaH volume only represents a sliver of their total inpatient volume. 

    Without guaranteed fee-for-service Medicare reimbursement, the average health system will find it difficult to devote the significant resources and investment that program creation and expansion requires. 

    If Congress moves to make the waiver program permanent, or at least extends it for several more years, state Medicaid programs and private payers may be more incentivized to follow suit and provide reimbursement for the care model. 

    Although legislation has been introduced to this end in Congress, action on this front in an election year is going to be challenging. 

    Hospitals charged employers and insurers 254% more than Medicare in 2022: study

    Posted on by • Posted in American Hospital Association (AHA), Health System, High Prices, Hospital, Hospital Industry, Medicare Reimbursement, Price Transparency, Rand Corporation • Leave a comment
    https://www.healthcaredive.com/news/hospitals-charge-employers-insurers-more-Medicare-Rand/715943/?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202024-05-15%20Healthcare%20Dive%20%5Bissue:62072%5D&utm_term=Healthcare%20Dive

    Hospitals with larger market shares were among the worst offenders, the Rand Corporation found.

    Dive Brief:

    • Employers and private insurers continue to pay hospitals more for inpatient and outpatient services than Medicare would have reimbursed, according to a new study from policy think tank the Rand Corporation.
    • In 2022, private insurers and employers paid on average 254% of what Medicare would have paid for the same care services — up from 224% two years prior. 
    • Health systems often argue they hike up commercial rates to offset losses from government underpayments, according to the study. However, a hospital’s market share, rather than population of Medicare or Medicaid patients, more accurately predicted pricing, with larger health systems charging higher prices.

    Dive Insight:

    Since 2021, health systems and insurers have been required to post pricing information for their 300 most common procedures as the government pushes to make healthcare prices more transparent.

    However, researchers have accused hospitals and insurers of failing to fully comply with the regulations. 

    Only 34.5% of 2,000 hospitals reviewed by nonprofit watchdog organization Patient Rights Advocate were deemed fully compliant with price transparency rules as of January. But, the CMS had only issued 14 civil monetary penalty notices to noncompliant hospitals as of February, according to the nonprofit.

    The Rand study found inpatient prices for hospital services were 255% above what Medicare paid in 2022 while outpatient hospital service prices averaged 289%, according to the report, which was based on an analysis of 4,000 hospitals across 49 states. 

    Prices for services at outpatient ambulatory surgical centers was slightly lower at 170% of Medicare payments.

    There were also differences in pricing by geography. Arkansas, Iowa, Massachusetts, Michigan and Mississippi kept relative prices below 200% of Medicare prices during the study period. However, others had relative prices above 300% of Medicare. Hospitals in Florida and Georgia negotiated the highest relative rates.

    Price transparency could be a tool for administrators of employer-sponsored plans to better negotiate employee benefits. Although employer-sponsored plans cover 160 million Americans, researchers said employers operate at a disadvantage when negotiating prices with providers and insurers due to a lack of detailed pricing information.

    “The widely varying prices among hospitals suggests that employers have opportunities to redesign their health plans to better align hospital prices with the value of care provided,” said Brian Briscombe, lead researcher for the Rand hospital price transparency project, in a statement. “However, price transparency alone will not lead to changes if employers do not or cannot act upon price information.”

    State and federal policymakers could rebalance negotiations by cracking down on noncompetitive healthcare markets, placing limits on payments for out-of-network hospital care or allowing employers to buy into Medicare or other public options, the report said.

    The nation’s largest hospital lobby, the American Hospital Association, has rejected previous analyses of pricing data — including reports from Patient Rights Advocate.

    On Monday, Molly Smith, AHA’s vice president for policy, pushed back against the Rand study, saying it was “suspiciously silent on the hidden influence of commercial insurers in driving up health care costs for patients, as evidenced by issues like the recent concerning allegations against MultiPlan.”

    Last week, Community Health Systems filed suit against MultiPlan alleging it had colluded with insurers to raise prices for patients and lower payments to providers. The lawsuit is the third against MultiPlan in under a year.

    Medicare finalizes physician pay cuts as Congress considers stepping in

    Posted on by • Posted in American Medical Association (AMA), Center for Medicare and Medicaid Services (CMS), Medicare Payment Advisory Commission (MedPAC), Medicare Reimbursement, Physician Compensation, Physician Fee Schedule, Primary Care • Leave a comment

    https://mailchi.mp/f12ce6f07b28/the-weekly-gist-november-10-2023?e=d1e747d2d8

    Last week, the Centers for Medicare and Medicaid Services (CMS) issued the final 2024 Physician Fee Schedule, which reduces overall payment rates for physicians by 1.25 percent, including a 3.4 percent decrease in the conversion factor for relative value units, compared to 2023. 

    The rule also implements a new add-on payment for complex evaluation and management visits, which is expected to boost pay for primary care physicians.

    The American Medical Association (AMA) strongly opposes these cuts and immediately appealed to Congress for a reprieve. In response, the Senate Finance Committee unanimously advanced a bill to the Senate floor that would reduce the conversion-factor rate cut from 3.4 percent to 2.15 percent, while also delaying reductions in Medicaid disproportionate share funding for safety-net hospitals. Senate Majority Leader Chuck Schumer (D-NY) has indicated he intends to assemble a broad healthcare bill, including some or all of these provisions, by the end of this year. 

    The Gist: Physicians were hopeful that inflation’s toll on labor and supply costs would earn them a break from continued Medicare pay cuts, but CMS remains committed to reductions within its budget neutrality framework.

    Earlier this year, the Medicare Payment Advisory Commission (MedPAC) recommended for the first time that physician payments be tied to an index of physician practice inflation, but that would require legislative intervention, which Congress has not taken up. 

    The AMA calculated that Medicare physician pay has lagged inflation by 26 percent since 2001, pointing to burnout and large numbers of physicians exiting the profession as a result. 

    Until calls for Medicare payment reform are heeded, physicians, like health systems, will have to adopt new, lower-cost models of care to cope with what they will continue to see as insufficient reimbursements.

    OPPS Rule to Update Outpatient Payments, Hospital Price Transparency

    Posted on by • Posted in Ambulatory Surgery Centers (ASC), Center for Medicare and Medicaid Services (CMS), Health System, Hospital, Hospital Industry, Medicare Intensive Outpatient Program, Medicare Reimbursement, Outpatient Prospective Payment System (OPPS), Price Transparency • Leave a comment
    https://revcycleintelligence.com/news/opps-rule-to-update-outpatient-payments-hospital-price-transparency?utm_source=nl&utm_medium=email&utm_campaign=newsletter

    CMS proposes in the Outpatient Prospective Payment (OPPS) rule to increase Medicare outpatient payments by 2.8 percent next year while bolstering hospital price transparency enforcement.

    The OPPS rule states that payment rates for hospitals that meet applicable quality reporting requirements will increase in 2024 based on the projected market basket percentage increase of 3.0 percent, less 0.2 percentage points for the productivity adjustment.

    Meanwhile, ambulatory surgical centers (ASCs) would also see a 2.8 percent increase in payment rates next year under the proposed ASC rule that was released alongside the OPPS rule.

    CMS also proposes to continue using the productivity-adjusted hospital market basket update to ASC payment system rates for another two years despite plans to shift away from the system as hospital procedures shift to ASC settings. But disruptions to care patterns during the COVID-19 pandemic have prompted CMS to extend the application of the hospital market basket update.

    The OPPS and ASC proposed rules also include a new benefit category for Medicare beneficiaries who require more frequent services than individual outpatient therapy visits but less intensive services than a partial hospitalization program. The benefit would be the Intensive Outpatient Program and include its own payment and program requirements for services across various settings, including hospital outpatient departments, community mental health centers, and federally qualified health centers.

    Starting next year, CMS also proposes establishing payment for intensive outpatient program services as part of Opioid Treatment Programs. These intensive behavioral health services are available for individuals with mental health conditions and substance use disorders.

    Other payment policies proposed in the rule include an update to Medicare payment rates for partial hospitalization program services, remote mental health services, and OPPS and ASC dental services, as well as changes to community mental health center Conditions of Participation (CoPs). The proposed rule also contains updates to the 340B payment rate, which CMS proposed to remedy via previous rulemaking to return improper payments to eligible hospitals.

    “This proposed rule reflects CMS’ commitment to ensure Medicare is comprehensive in its ability to address patient needs, filling gaps in the health care system including behavioral health,” Meena Seshamani, MD, Deputy Administrator and Director for CMS’ Center for Medicare, said in a statement. “Through these proposals, we will ensure people get timely access to quality care in their communities, leading to improved outcomes and better health.”

    HOSPITAL PRICE TRANSPARENCY CHANGES ON HORIZON

    In addition to payment updates, the OPPS proposed rule also includes extensive updates to hospital price transparency requirements to increase compliance and enforcement.

    Previous OPPS rules have required hospitals to make standard charges, including payer-specific negotiated rates, available to the public in a machine-readable file on their websites and through a more patient-friendly list of shoppable services. Hospitals face financial penalties of up to $2 million if they do not comply with the requirements.

    However, a recent website assessment conducted by CMS found that about 70 percent of hospitals were fully meeting display criteria for the machine-readable file, 27 percent were partially meeting display criteria, and just 3 percent failed to post any required pricing data online by the fall of 2022. The rates improved from a previous compliance assessment in early 2021 when 30 percent of hospitals did not publish the required pricing data.

    However, the latest OPPS rule aims to increase compliance by altering enforcement actions. For example, the rule would allow CMS to require an authorized hospital official to certify the accuracy and completeness of the data in the machine-readable file. Hospitals may also have to submit additional documentation to determine hospital compliance and an acknowledgment of receipt of the warning notice if CMS deems them out of compliance.

    If CMS has to take action to address noncompliance, CMS may also notify the hospital’s health system leadership of the issue and work with the health system to address compliance issues across its system.

    Finally, CMS proposes to publicize a hospital’s assessment of compliance, any compliance actions taken against a hospital, and notifications sent to health system leadership.

    Additionally, the OPPS rule would update hospital price transparency requirements, requiring hospitals to display the required pricing data using a CMS template versus any machine-readable file format. Pricing data would also have to be encoded in a CSV or JSON format using a CMS template layout and other specified technical instructions.

    CMS aims to increase machine-readable file accessibility by proposing a requirement to place a “footer” at the bottom of a hospital’s homepage that links to the webpage with the pricing data. Hospitals would also have to ensure that a .txt file is included in the root folder of the publicly available website chosen by the hospital for posting its machine-readable format.

    Healthcare stakeholders can comment on the OPPS and ASC proposed rules through September 11th. CMS expects to release the final rules in November.

    CMS proposes $9B repayment to 340B hospital participants

    Posted on by • Posted in Center for Medicare and Medicaid Services (CMS), Dept of Health and Human Services (HHS), District Court, District Court of Appeals, Health System, Hospital, Hospital Industry, Medicare 340B Drug Discount Program, Medicare Budget Neutrality, Medicare Reimbursement, Supreme Court • Leave a comment

    https://mailchi.mp/cc1fe752f93c/the-weekly-gist-july-14-2023?e=d1e747d2d8

    Earlier this week, the Centers for Medicare and Medicaid Services (CMS) issued a proposal to remedy its four years of payment cuts to the more than 1,600 hospitals participating in the 340B Drug Pricing Program through one-time, lump-sum payments that will total roughly $9B. 

    In 2018, CMS reduced drug reimbursement to 340B covered-entity hospitals by nearly 30 percent, in an attempt to align reimbursement with hospitals’ actual drug acquisition costs. The Supreme Court overturned those cuts in 2022, ruling that the Department of Health and Human Services (HHS) had violated rulemaking procedure. As CMS rulemaking on Medicare payment must be budget-neutral, the agency will offset the remedy payments with a 0.5 percent cut to all hospitals for non-drug items and services covered under the Hospital Outpatient Prospective Payment System (OPPS) over the next 16 years. Stakeholders have until September 5th to comment on the proposed rule. Once the final rule is published later this year, CMS plans to repay 340B participant hospitals within 60 days of their application for remedy.

    The Gist: After worries about how last year’s Supreme Court ruling would be implemented, 340B participant hospitals will be relieved to receive their payment corrections up front instead of over time, especially given current margin challenges.

    But while this issue is now set to be resolved, other critical decisions about the 340B program’s fate are pending before courts. Earlier this year, Bayer and EMD Serono became the 20th and 21st drugmakers to restrict discounts to contract pharmacies, following an appellate court decision in January that sided with the pharmaceutical manufacturers.

    Meanwhile, appellate courts in other jurisdictions are set to hear at least two more cases on the issue, amid conflicting rulings about whether HHS can enforce contract pharmacy discounts.

    Physicians beyond ‘breaking point’ want Medicare pay reform

    Posted on by • Posted in American Medical Association (AMA), Health Policy, Healthcare Reform, Inflation, Medicare Payment Advisory Commission (MedPAC), Medicare Physician Fee Schedule (MPFS), Medicare Reimbursement, Physician Reimbursement • Leave a comment
    https://www.beckershospitalreview.com/finance/physicians-beyond-breaking-point-want-medicare-reform.html?origin=CFOE&utm_source=CFOE&utm_medium=email&utm_content=newsletter&oly_enc_id=2893H2397267F7G

    Physicians at the American Medical Association Annual Meeting called for an overhaul of the Medicare payment system, arguing that it is outdated and threatens the survival of independent practices and patients’ access to care.

    “This cannot wait; we are past the breaking point. Congress must urgently address physician concerns about Medicare to account for inflation and the post-pandemic economic reality facing practices nationwide,” AMA President Jack Resneck Jr., MD, said in a June 12 news release. “Our patients are counting on us to deliver the message that access to health care is jeopardized by Medicare’s payment system. Being mad isn’t enough. We will develop a campaign — targeted and grass roots — that will drive home our message.”

    Inflation, the pandemic, declining reimbursements and rising cost are making it more challenging for independent physicians to maintain their autonomy and are jeopardizing access to care, according to the AMA, which argues that CMS physician payments have declined 26 percent from 2001 to 2023 after accounting for inflation.

    In January, the Medicare Payment Advisory Commission called for a physician payment update tied to the Medicare Economic Index for the first time, and, in April, a group of House members introduced a bill that would provide annual inflation updates to the Medicare fee schedule based on the index.

    “Duct-taping the widening cracks of a dilapidated payment system has put us in this precarious situation,” Dr. Resneck said. “Physicians are united in our determination to build a solid foundation rather than further jury-rigging the system.”