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No Surprises Act implementation includes telehealth
https://www.healthcarefinancenews.com/news/no-surprises-act-implementation-includes-telehealth
Independent physician groups, which include telehealth docs, must now accept a rate that someone else has negotiated, expert says.
The No Surprises Act has providers scrambling to understand the implications of a law that went into effect earlier this month.
Under the law, patients treated by an out-of-network physician can only be billed at the in-network rate. It protects patients from receiving surprise medical bills from the ER or air ambulance providers or for non-emergency services from out-of-network physicians at in-network facilities.
Patients can no longer receive balance bills – the difference between what the provider charges and what the insurer pays – or be charged a larger cost-sharing amount.
The congressional intent was to save patients sometimes thousands of dollars in unexpected, or surprise, medical bills. But applying the No Surprises Act to clinical care is being left to providers to sort out.
A big question is the definition of an emergency and the benchmark used to determine when it ends, according to Kyle Faget, a partner at Foley who is co-chair of the firm’s Health Care and Life Sciences Practice Groups. She asked: Does the emergency end when the patient is stabilized, or should another standard apply? This includes emergency services for mental health and substance-use disorders.
Another question is around pre-planned services. Patients have to be notified who is providing the care and whether the physician is in-network. If the physician is out-of-network, patients must provide consent. But that can be tricky, for instance, if a patient scheduled for a planned C-section gets an out-of-network doctor who was not scheduled at the time the appointment was made.
At some hospitals, a new layer of administration is needed to comply with the law, Faget said.
Another area not well understood is how the law affects telehealth consults in the ER.
TELEHEALTH AND THE NO SURPRISES ACT
The law states that if treated by a telehealth clinician, the patient can only be billed the in-network rate, said Faget, who specializes in telehealth law.
Telehealth is often used in the ER, according to Faget. Most ER visits require a physician consultation, with hands-on medical care provided by a clinician other than the physician.
Pre-COVID-19, providers were in the embryonic stage of providing virtual emergency care, she said. The pandemic, and a shortage of physicians, spurred virtual care in the ER.
These telehealth providers often work on a contracted basis. They are likely credentialed at the hospital but are not hospital employees, Faget said.
This means they are not credentialed with the insurer. Under the No Surprises Act, they are now subject to the in-network rates negotiated by the hospital.
Telehealth ER physicians could negotiate their own contracts with insurers, but as a small group, they are not likely to get the higher rates they had prior to the implementation of the No Surprises Act.
“It’s an arduous contracting process, and small-group bargaining power is low,” Faget said. “The big hospital system has bargaining power. Those groups providing telehealth services won’t necessarily have agreements in place and, by definition, are out-of-network.”
Independent physician groups, which include telehealth docs, must now accept a rate that someone else has negotiated, Faget said. This fact can be more of an issue than the lower rate they’re now being paid, she said.
“I think telehealth will adapt,” Faget said. “I think it will become the way of doing business.”
WHY THIS MATTERS
The bottom line is that the No Surprises Act is doing what it promised to do – saving patients from getting a large bill not covered by insurance.
Surprise bills are a moral and ethical issue, Faget said. Patients, at their most vulnerable in the ER, are sent home only to get a $5,000 bill they never saw coming.
“It’s like kicking a person when they’re down,” Faget said.
However, in the larger healthcare ecosystem, ending surprise medical bills will ultimately result in cost-shifting, she said.
“Think about the system globally: somebody is paying for something somewhere,” Faget said. “At the end of the day, somebody’s going to have to pay.”
THE LARGER TREND
Providers have told her that the No Surprises Act incentivizes insurance companies to lower their payments, Faget said.
The American Society of Anesthesiologists has accused BlueCross BlueShield of North Carolina of doing this. A letter sent by BCBS of North Carolina to anesthesiology and other physician practices this past November threatens to terminate physicians’ in-network status unless they agree to payment reductions ranging from 10% to over 30%, according to ASA.
The ASA saw this as proof of its prognostication to Congress upon passage of the No Surprises Act: that insurers would use loopholes in the law to leverage their market power.
The AHA and AMA have sued the Department of Health and Human Services over implementation of a dispute-resolution process in the law they say favors the insurer. The arbitrator must select the offer closest to the qualifying payment amount. Under the rule, this amount is set by the insurer, giving the payer an unfair advantage, according to the lawsuit.
Tower Health fires physician accused of prescribing ivermectin, hydroxychloroquine to treat COVID-19
A Pennsylvania physician accused of prescribing ivermectin and hydroxychloroquine to treat and prevent COVID-19 has been terminated from Tower Health, PennLive reported Feb. 4.
Edith Behr, MD, is allegedly linked to Christine Mason, a woman who used a Facebook account to connect people to a physician for hydroxychloroquine and ivermectin prescriptions. A social media user claimed Dr. Behr was the source of the prescriptions and reported her to authorities and her employer, according to PennLive.
West Reading, Pa.-based Tower Health officials became aware of the allegations against Dr. Behr Feb. 2 and took immediate action.
“Tower Health became aware yesterday of the allegations involving Dr. Edith Behr prescribing ivermectin and hydroxychloroquine for the treatment of COVID-19,” Tower Health said in a Feb. 3 statement to PennLive. “We investigated the matter and, as a result, Dr. Behr’s employment with Tower Health Medical Group has been terminated effective immediately.”
Dr. Behr was a surgeon at Phoenixville (Pa.) Hospital, which is owned by Tower Health, according to the report.
Ivermectin and hydroxychloroquine have not been approved by the FDA for prevention or treatment of COVID-19.
Labor Market Trends
Good morning. Here’s Axios chief economic correspondent Neil Irwin and markets correspondent Emily Peck with what you need to know about today’s surprising jobs numbers.
After days of doom-and-gloom talk about how bad the January jobs numbers would be due to the Omicron variant, they turned out to be, um, great?
- Employers added 467,000 jobs last month, despite millions out sick.
Why it matters: It’s rare for any jobs numbers to be stunning, but these were. They leave little doubt that this remains a tight job market in which employers are doing everything they can to hold on to their workers.
The big picture: Some of the biggest job gains were in categories that have strong seasonal patterns, normally adding workers in the fall and then cutting those temporary workers in January.
- But employers, desperate for staff, appear to have held onto those workers in greater numbers than in a normal year.
- Due to the statistical process of seasonal adjustment, “cutting fewer workers than usual for this time of year” gets translated as “adding lots of jobs.”
By the numbers: Leisure and hospitality added 151,000 jobs; retail added 61,000; and transportation and warehousing added 54,000.
Between the lines: The report offered more evidence that this is an exceptionally tight labor market with inflationary pressures brewing, giving the Federal Reserve the green light for interest rate increases.
- Average hourly earnings rose a robust 0.7%, and are up 5.7% over the last year. Employers are being forced to pay up to fill their job openings.
Yes, but: Omicron really did have an effect. The report said 6 million people were unable to work because their employers were closed or lost business due to the pandemic, up from 3.1 million in December.
What they’re saying: “Had the prior relationship between Covid cases and employment held true, 800k daily new Covid cases would have led to 2.3 million job losses,” Julia Pollak, chief economist at ZipRecuiter, tweeted. “Instead, we saw 467,000 job GAINS!”
The bottom line: This is an incredibly strong labor market that is poised to strengthen further as Omicron fades.
Thought of the Day: On Great Leaders
Why is America’s Covid-19 death rate so high?
Covid-19 death rates in the United States are “eye-wateringly” high compared with other wealthy nations—a problem that several health experts say underscores the shortfalls of the country’s pandemic response.
U.S. Covid-19 death rates exceed those of other wealthy nations
According to CDC data, over 880,000 Americans have died from Covid-19 since the beginning of the pandemic—a death toll greater than that of any other country. And during the current omicron wave, Covid-19 deaths are now greater than the peak number seen during the delta wave and more than two-thirds as high as record numbers seen last winter before vaccines were available, the New York Times reports.
Moreover, since Dec. 1, when omicron was first detected in the United States, the proportion of Americans who have died from Covid-19 has been at least 63% higher than other large, wealthy countries, including Britain, Canada, France, and Germany, according to a Times analysis of mortality figures.
Currently, the daily Covid-19 death rate in the United States is nearly double that of Britain and four times that of Germany. The only large European countries to surpass the United States’ Covid-19 death rates have been the Czech Republic, Greece, Poland, Russian, and Ukraine—all of which are less wealthy nations where the most effective treatments may be limited.
“Death rates are so high in the States—eye-wateringly high,” said Devi Sridhar, head of the global public health program at the University of Edinburgh. “The United States is lagging.”
Similarly, Joseph Dieleman, an associate professor at the University of Washington, said the United States “stands out” with its high Covid-19 death rate. “There’s been more loss than anyone wanted or anticipated,” he said.
Vaccination shortfalls plague the U.S.
Lagging Covid-19 vaccination rates among Americans likely contributed to the country’s outsized death toll compared with other nations, several health experts said.
Currently, around 64% of the U.S. population has been fully vaccinated. However, several peer countries, including Australia (80%), Canada (80%), and France (77%), have achieved higher vaccination rates.
Unvaccinated people make up the majority of hospitalized Covid-19 patients, according to the Times, but lagging vaccination and booster rates among vulnerable groups, such as older Americans, has also led to increased hospitalizations.
Around 12% of Americans ages 65 and older are not fully vaccinated, and among those who are fully vaccinated, 43% still have not received a booster shot, leaving them with waning immunity against the omicron variant. In comparison, only 4% of Britons ages 65 and older are not fully vaccinated, and only 9% have not had a booster shot.
“It’s not just vaccination—it’s the recency of vaccines, it’s whether or not people have been boosted, and also whether or not people have been infected in the past,” said Lauren Ancel Meyers, director of the University of Texas at Austin’s Covid-19 modeling consortium.
Similarly, former FDA Commissioner Scott Gottlieb said that the United States‘ lagging vaccination rates compared to the U.K.’s, particularly for boosters, may be due to “protracted wrangling” that “may have sowed confusion, sapping consumer interest.”
How the U.S. could fare in future Covid-19 waves
According to some scientists, the gap between the United States and other wealthy nations may soon begin to narrow. Although U.S. vaccination rates have been slow, the delta and omicron waves have infected so many people that overall immunity against the coronavirus has increased—which could potentially help blunt the effect of future waves.
“We’ve finally started getting to a stage where most of the population has been exposed either to a vaccine or the virus multiple times by now,” said David Dowdy, an epidemiologist at the Johns Hopkins Bloomberg School of Public Health. “I think we’re now likely to start seeing [American and European Covid-19 death rates] be more synchronized going forward.”
However, other experts noted that the United States has other disadvantages that could make future Covid-19 waves difficult. For example, many Americans have chronic health problems, such as diabetes and obesity, that increase the risk of severe Covid-19 outcomes.
Overall, health experts said the impact of future Covid-19 waves will depend on what new variants emerge, as well as what level of death people decide is tolerable.
“We’ve normalized a very high death toll in the U.S.,” said Anne Sosin, who studies health equity at Dartmouth University. “If we want to declare the end of the pandemic right now, what we’re doing is normalizing a very high rate of death.”
U.S. added 467,000 jobs in January despite omicron variant surge
The U.S. economy added 467,000 jobs in January as the omicron variant spiked to record heights, with the labor market performing better than many expected two years after the pandemic began.
The unemployment rate ticked up slightly to 4 percent, from 3.9 percent the month before.
The monthly report, released by the Department of Labor, stems from a survey taken in mid-January, around the time the omicron variant was beginning to peak, with close to 1 million new confirmed cases each day. The rapid spread during that period upended many parts of the economy, closing schools, day cares, and a number of businesses, forcing parents to scramble.
But the labor market, according to the new data, performed very well during that stretch.
In addition to the robust January, the Department of Labor also revised upward the figure for December’s jobs report, to 510,000 from 199,000, and November, to 647,000 from 249,000. That means that there were some 700,000 more jobs added at the end of last year than previously estimated — showing a labor market with momentum heading into the new year.
The data sets show a labor market that continues to recover at a strong pace from the pandemic’s worst disruption in March and April of 2020.
New outbreaks and variants have sent shockwaves through the economy since then, but the labor market has continued to return, with companies working to add jobs and wages steadily rising.
The industries experiencing growth in January were lead by the leisure and hospitality sector, which added 151,000 jobs on the month, mostly in restaurants and bars. Professional and business services added 86,000 jobs. Retailers added 61,000 jobs in January, which is typically an off month. Transportation and warehousing added 54,000 jobs.
The labor market’s participation rate, a critical measurement that has never fully recovered from losses during the pandemic’s earliest days, also went up significantly, to 62.2 percent from 61.9 percent. That shows more people are reentering the labor force, looking for work.
Average hourly earnings increased by 23 cents on the month to $31.63, up 5.7 percent over the last year. However, those gains for many people have largely been wiped out by rising prices from inflation.
The data was collected during a tumultuous period. Nearly nine million workers were out sick around the time the survey was taken, and some of them could have been counted as unemployed based on the way the survey is conducted.
January is traditionally a weak month for employment when retail and other industries shed jobs after the holiday season. Economists say that seasonal adjustments made to the survey’s data to account for this have the potential to distort the survey in the other direction, given that the holiday shopping boom appeared to take place earlier this year than typical.
As such, predictions for job growth for the month had been all over the map. Analysts surveyed by Dow Jones predicted an average of about 150,000 jobs added for the month, in what would be the lowest amount added in a year. Some economists predicted job losses, of up to 400,000.
Last year was a strong year for growth in the labor market, with the country adding an average of more than 550,000 jobs a month — regaining some 6.5 million jobs lost in the pandemic’s earlier days, after the Department revised its numbers. The country has about 2.9 million fewer jobs than it had before the pandemic, according to the figures released Friday.
“Omicron is going to make it look like things dropped off a cliff in January, but overall they did not,” said Drew Matus, chief market strategist for MetLife Investment Management.
Some economists like Matus say that the prospects for such rapid regrowth are more complicated this year, with the fiscal measures that boosted the economy during the pandemic’s first two years, like generous government aid, and record low interest rates from federal bankers, having largely expired, and the country’s confidence in a virus-free future dented after the winter wave.
Since the rollout of vaccines last year, there have been hopes that a return to a more typical rhythm of life could encourage some of the roughly two million people who have left the labor force during the pandemic to seek work anew, but thus far, continued threats from variants — and uncertainty after more closures of schools, daycares, and office — have prevented this from materializing in a substantial way.
There are signs that the omicron exacted a toll on the economy during its peak.
Weekly unemployment claims swelled mid-month to its highest level since October, though the numbers have come down in the two weeks since. Other statistical markers like passenger traffic at airports, hotel revenues, and dining reservations also took a hit during the month.
Recent months continue to be marked by incredible churn in the labor market, as record numbers of workers are switching jobs. In December, some 4.3 million people quit or changed jobs — a number which was down from an all-time high in November but still at elevated. Employers continue to report near record numbers of job openings: the Bureau of Labor Statistics said they reported some 10.9 million openings last month.
Understanding the implications of using agency nurses
The Great Nursing Resignation, and hospitals’ growing reliance on expensive agency labor (a.k.a. “travelers”) has grabbed headlines, for good reason. But lately we’ve heard a couple of anecdotes from health system leaders about the second-order impacts of the phenomenon that are worth considering as well.
First, as the ranks of agency nurses at hospitals have swelled, full-time employed nurses’ morale has plummeted—tenured nurses are having to orient their new temporary co-workers, then watch them earn up to three times as much money for the same work.
At the same time, willingness to work overtime among employed nurses has dropped. That’s not just because of burnout—it turns out that the nurses who were most likely to take overtime shifts are also more likely to have chosen to leave full-time employment to become travelers, where they are even more richly rewarded for working extra shifts. So, the “productivity” of the remaining corps of staff nurses has dropped, even as caseloads have increased.
One other implication we’ve heard about recently: the economic impact of “observation” cases, where patients are held in a staffed bed but not admitted—already a bad bargain for hospitals—has gotten worse. That’s because the cost of deploying staff to care for those patients has gone up, due to wage inflation and use of travelers. It’s hard to overstate the level of staffing crisis at most hospitals today, and the rapid growth in reliance on temporary staff will have consequences lasting well beyond the current surge.
How “Goliaths” that adapt can retain industry dominance
A thought-provoking piece in this week’s Harvard Business Review about the underrated advantages longstanding industry giants have over disruptors got us thinking about health system strategy. The authors highlighted several companies that have enjoyed sustained success over a century or more, including agricultural behemoth Deere and Company, and shipping giant company A.P. Møller-Maersk, which wielded “strategic incumbency” to successfully innovate and pursue new strategies, leveraging scale, trusted customer relationships, and long-term planning capabilities—attributes that new market entrants often lack when looking to disrupt established consumer channels.
The Gist: In a market where healthcare unicorns constantly garner headlines, the article offers a counterintuitive perspective about the value of incumbency.
Health system leaders might look to the experience of Maersk, which moved from a supply-driven focus (pushing its products to customers), to a demand-driven strategy (navigating customers through logistical pain points), using technology to maximize its vast asset portfolio.
Likewise, health systems have an abundant “supply” of care delivery assets, and now need to build the connective tissue to make the care experience across those point solutions seamless for patients.
Hospitals seek government help on staffing costs
The American Hospital Association (AHA) is asking Congress for an additional $25B to help hospitals offset high labor costs, largely incurred by the need to rely on travel nurse staffing firms that charge two to three times pre-pandemic rates. The AHA, along with 200 members of Congress, is urging the Federal Trade Commission to investigate the staffing agencies for anti-competitive activity, although the agency has previously declined to do so.
The Gist: The Department of Health and Human Services (HHS) is now releasing $2B in of provider relief dollars from the CARES Act. Beyond that, after nearly two years and $178B of federal support, hospitals shouldn’t count on additional funds from the government, even as costs of labor and supplies continue to rise.
Instead, we’d expect more scrutiny over how the remaining relief dollars are spent. Federal support during the pandemic has masked structural economic flaws in provider economics, and we expect 2022 will be a year of financial reckoning for many hospitals and health systems.
HENRY KOTULA 