Tag Archives: Medicare

Senior House Democrats’ New Bill Ramps Up the Medicare Expansion Debate

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Earlier this week, Congresswomen Rosa DeLauro (D-CT) and Jan Schakowsky (D-IL) introduced legislation, the Medicare for America Act, that would greatly expand Medicare coverage while maintaining employer-sponsored health insurance for those who have it and want to keep that coverage, employers would have an option to pay for their employees to be in the new system.

Under the proposal Medicare plan beneficiaries would still be required to pay premiums and insurance deductibles however, those costs would be capped, with premiums set at a maximum of 9.69 percent of the individual’s income. The plans would also be required to cover prescription drugs, dental, vision, and hearing services, as well as long-term supports and services for seniors and Americans with disabilities.

The bill is funded by phasing out the GOP tax cuts put in place last year as well as creating a 5 percent capital gains tax on high income earners, raising Medicare payroll and net investment income taxes, and increasing taxes on goods like tobacco, beer, liquor and sugar-sweetened drinks. Additionally, states would be required to pay into the system.

Click here for the legislation, and here for a summary.

 

Misconceptions About Health Costs When You’re Older

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Misconceptions About Health Costs When You’re Older

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Some significant expenses decline as we age: Most mortgages are eventually paid off, and ideally children grow up and become self-supporting.

But health care is one area in which costs are almost certain to rise. After all, one of the original justifications for Medicare — which kicks in at age 65 — is that older people have much higher health care needs and expenses.

But there are a few common misunderstandings about health costswhen people are older, including the idea that money can easily be saved by reducing wasteful end-of-life spending.

Half our lifetime spending on health care is in retirement, even though that represents only about 20 percent of a typical life span. Total health care spending for Americans 65 and older is about $15,000 per year, on average, nearly three times that of working-age Americans.

Don’t expect Medicare to provide complete protection from these expenses.

Traditional Medicare has substantial gaps, leaving Americans on the hook for a lot more than they might expect. It has no cap on how much you can pay out of pocket, for example. Such coverage gaps can be filled — at least in part — by other types of insurance. But some alternatives, such as Medicare Advantage, aren’t accepted by as many doctors or hospitals as accept traditional Medicare.

On average, retirees directly pay for about one-fifth of their total health care spending. Some spend much more.

One huge expense no Medicare plans cover is long-term care in a nursing home.

Over half of retirement-age adults will eventually need long-term care, which can cost as much as $90,000 per year at a nursing home. Although most who enter a nursing home don’t stay long, 5 percent of the population stays for more than four years. You can buy separate coverage outside the Medicare program for this, but the premiums can be high, especially if you wait until near retirement to buy.

Although Medicare is thought of as the source of health care coverage for retirees, Medicaid plays a crucial role.

Medicaid, the joint federal-state heath financing program for low-income people, has long been the nation’s main financial backstop for long-term care. Over 60 percent of nursing home residents have Medicaid coverage, and over half of the nation’s long-term care is funded by the program.

That isn’t because most people who require long-term care have low incomes. It’s because long-term care is so expensive that those needing it can frequently deplete their financial resources and then must turn to Medicaid.

A recent working paper from the National Bureau of Economic found that, on average, Medicaid covers 20 percent of retiree health spending. The figure is larger for lower-income retirees, who are more likely to qualify for Medicaid for more of their retirement years.

A widely held view is that much spending is wasted on “heroic” measures taken at the end of life. Are all the resources devoted to Medicare and Medicaid really necessary?

First, let’s get one misunderstanding out of the way. The proportion of health spending at the end of life in the United States is lower than in many other wealthy countries.

Still, it’s a tempting area to look for savings. Only 5 percent of Medicare beneficiaries die each year, but 25 percent of all Medicare spending is on individuals within one year of death. However, the big challenge in reducing end-of-life spending, highlighted by a recent study in Science, is that it is hard to know which patients are in their final year.

The study used all the data available from Medicare records to make predictions: For each beneficiary, it assigned a probability of death within a year. Of those with the very highest probability of dying — the top 1 percent — fewer than half actually died.

“This shows that it’s just very hard to know in advance who will die soon with much certainty,” said Amy Finkelstein, an M.I.T. economist and an author of the study. “That makes it infeasible to make a big dent in health care spending by cutting spending on patients who are almost certain to die soon.”

That does not mean that all the care provided to dying patients — or to any patient — is valuable. Another study finds that high end-of-life spending in a region is closely related to the proportion of doctors in that region who use treatments not supported by evidence — in other words, waste.

“People at high risk of dying certainly require more health care,” said Jonathan Skinner, an author of the study and a professor of economics at Dartmouth. “But why should some regions be hospitalizing otherwise similar high-risk patients at much higher rates than other regions?”

In 2014, for example, chronically ill Medicare beneficiaries in Manhattan spent 73 percent more days in the hospital in their last two years of life than comparable beneficiaries in Rochester.

“There absolutely is waste in the system,” said Ashish Jha, director of the Harvard Global Health Institute. But, he argues, waste is present throughout the life span, not just at the end of life: “We have confused that spending as end-of-life spending is somehow wasteful. But that’s not right because we are terrible at predicting who is going to die.”

Of course, beyond any statistical analysis, there are actual people involved, and wrenching individual decisions that need to be made.

“We should do all we can to push waste out of the system,” Dr. Jha said. “But spending more money on people who are suffering from an illness is appropriate, even if they die.”

 

 

DOJ recovered $2.5 billion in 2018 healthcare false claim cases

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DOJ recovered $2.5 billion in 2018 healthcare false claim cases

 

 

 

 

 

 

 

 

 

 

According to the DOJ, this is the ninth consecutive year that the organizations’ civil healthcare fraud settlements and judgments have exceeded $2 billion.

As part of the federal government’s increasing focus on issues of healthcare fraud, particularly in the Medicare space, the U.S. Department of Justice recovered $2.5 billion in settlements and judgments from False Claims Act Cases over the past year.

According to the DOJ, this is the ninth consecutive year that the organizations’ civil health care fraud settlements and judgments have exceeded $2 billion.

While the $2.5 billion number represents federal losses, the DOJ also said it also helped recover significant funds for state Medicaid programs

“Every year, the submission of false claims to the government cheats the American taxpayer out of billions of dollars,” Principal Deputy Associate Attorney General Jesse Panuccio said in a statement.

“In some cases, unscrupulous actors undermine federal healthcare programs or circumvent safeguards meant to protect the public health … The nearly three billion dollars recovered by the Civil Division represents the Department’s continued commitment to fighting fraudsters and cheats on behalf of the American taxpayer.”

The False Claims Act has its roots in groups trying to defraud the military during and after the Civil War and was significantly strengthened since 1986 when Congress increased incentives for whistleblowers to file lawsuits alleging false claims.

In healthcare, organizations across the industry were hit with False Claims cases including drug companies, medical device manufacturers, payer organizations and healthcare providers.

The single largest recovery over the past year was a $625 million settlement paid by drug wholesaler AmerisourceBergen to resolve a number of claims including that the company illegally repackaged injectable cancer drugs into pre-filled syringes and billing multiple doctors for individual drug vials.

The DOJ also brought cases against drug companies who increased drug prices by funding Medicare co-payments meant to serve as a check on healthcare costs.

In one instance, United Therapeutics Corporation paid $210 million over allegations that it illegally used a foundation to funnel co-pay obligations for Medicare patients taking its drugs. Pfizer paid nearly $24 million in a similar case, with the government alleging that the company raised the price of a cardiac drug called Tikosy by 40 percent over three months

One major case against Massachusetts-based medical device company Alere resulted in a $33.2 million settlement over allegations that it sold unreliable diagnostic devices meant to detect acute coronary syndromes, heart failure, drug overdose and other serious conditions.

On the provider side, the DOJ recovered $270 million from DaVita subsidiary HealthCare Partners Holdings for upcoding and providing inaccurate information to inflate Medicare Advantage payments.

Another major case was against former health system Health Management Associates which allegedly engaged in major Medicare fraud including illegal kickbacks to physicians for referrals, incorrect billing for observation and outpatient services and inflated facility fees.

When it comes to health plans, the government’s case against UnitedHealth Group over allegations that it knowingly obtained inflated risk adjustment payments for its Medicare Advantage beneficiaries is still ongoing.

 

 

Have enough beds? Demographic trends paint an alarming picture

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Have enough beds? Demographic trends paint an alarming picture

Healthcare providers know that inpatient volumes are down over historic levels. (But let’s not talk […]

Healthcare providers know that inpatient volumes are down over historic levels. (But let’s not talk about emergency department volumes—those are WAY up.)  They know this trend originates mostly with Medicare beneficiaries. They also know the causes: migration to outpatient services, observation day rules, intense focus on decreasing length of stay, and reduced readmissions as part of their quality initiatives.

What they may miss, however, is that this trend also has something to do with the declining average age of our nation’s senior population—a phenomenon that first began in 2005 and will continue until about 2020.  In 2005, the average age of our nation’s senior population was 75.2 years; in 2020, the average age is expected to be 74.4 years.

This fact is important because older seniors consume significantly greater healthcare resources than younger seniors. Today, those over 65 represent about 15 percent of the total U.S. population. By 2020, one out of six Americans will be 65 or older, rising to 22 percent by 2040. Understanding how this population is distributed among age cohorts is critically important not only in understanding current trends in reduced utilization, but also in preparing for the future.

Taking a Closer Look
This increasing proportion of the population that are seniors is important because the average Medicare beneficiary consumes about four times the hospital-based services as the average commercially insured person. But it is just as important to look more closely at consumption patterns within the senior population. Those between ages 75 and 84 consume about 60 percent more services than seniors ages 65 to 74. Those age 85 and above consume about two-and-a-half times as much.

According to U.S. Census forecasts, in 2021, the over-75 population will make up the lowest percentage of the senior Medicare population in recent history, at about 41 percent. By 2040, seniors older than 75 will constitute 55 percent of the total senior population. This fact alone would suggest that we are in for a reversal of declining volume patterns—but by how much?

The answer is that if nothing is done to further reduce admissions and days per 1,000 for the senior Medicare population, inpatient days should almost double from about 70 million today to about 130 million in 2040 on the basis of demographic changes alone. That represents a need for some 220,000 additional beds at 75 percent capacity by 2040—never mind all the other healthcare services that will be needed. But even as there is general recognition among healthcare leaders of the advent of an aging population, there is also the general sense that somehow, we will not need the same level of resources to meet that demand as we do today.

Where does that sense of assurance come from? Apparently, it stems from the belief that unnecessary and excess utilization exists purely due to financial reasons, and that even more of the care delivered on an inpatient basis could be performed on an outpatient basis or at home with better monitoring and intervention through new technologies. But there also appears to be an ignoring of the well-known trend for the population becoming increasingly co-morbid at ever-younger ages. Additionally, some believe that increased focus on addressing social determinants of health, which impact 64 percent of health outcomes, will reduce need for medical services.

All of these assumptions may be true, in theory. In practice, however, as a senior healthcare executive and registered nurse said to me recently, “People are really sick. You have no idea.” There is also the enormous question of how one staffs and gets paid for programs and investments that might reduce demand for hospital-based services. The economics of today’s medicalized approach to health care is unprepared to address this.

A Critical Issue for Leadership
This is an issue that should be of paramount importance to healthcare providers. As seniors comprise a greater portion of our population, demand for inpatient and post-acute services will significantly increase. The hope and dream expressed in the view that hospital-based utilization might be reduced springs from a terrible reality: Hospitals in general, with the possible exception of high-end tertiary/quaternary services, lose money on government-reimbursed volume—and this will only get worse as cost inflation continues to exceed government reimbursement trends.

The prospect of the demand for inpatient days nearly doubling over the next 20 years paints a horrifying financial picture. Who, then, would not want to hope that something magical will happen to prevent a scenario that logic and data tell us is likely to occur?

It’s time for healthcare leaders to take a hard look at the trends around senior aging and have tough discussions with their executive teams and boards about the impact these trends could have on their organizations’ futures—and what they should be doing now to prepare.

 

 

 

A Brief Look at Medicare Market Share for Six Major Metro Areas

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https://www.markfarrah.com/mfa-briefs/a-brief-look-at-medicare-market-share-for-six-major-metro-areas/

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Medicare Advantage plans continue to be an attractive option for the rapidly increasing senior population.  As of November 2018, total Medicare Advantage (MA) membership stood at over 21.6 million, representing approximately 34% of the 63.7 million Americans eligible for Medicare.  Health plan enrollment and market share data are important metrics for health insurers to assess in order to identify opportunities and make better business decisions about products and services.  Companies not only look at their own market positions but also routinely analyze competitor membership to evaluate relative market share.  Industry analysts often assess market share at the county or metropolitan statistical area (MSA) level in order to gain a more complete competitive picture of the market.  This brief presents an overview of Medicare market demographics and market share data, with a focus on health plan market position for six major metropolitan statistical areas (MSAs) in the U.S.

Competition and Market Share

For the purposes of this brief, MFA first looked at the competitive mix in the Medicare and Medicare Advantage markets through analysis of enrollment figures from the Health Coverage Portal™ and Medicare Business Online™ by metropolitan areas in the United States. 

  • Seniors have a choice between coverage offered by original Medicare and Medicare Advantage (MA).  While potential market size is an important metric, understanding the insurance preferences of seniors requires a closer look at enrollment within each area.  How seniors are behaving as consumers varies greatly among the metropolitan areas.  To shed more light on these differences, Mark Farrah Associates calculated the penetration rate for original Medicare & Medicare Advantage plans.  Penetration rate is calculated by dividing the number of plan members by the number of those eligible for Medicare.  The penetration rate provides the overall market share which can be used to analyze seniors’ choice between sticking with original Medicare and choosing a Medicare Advantage plan.
  • There is a greater degree of variability across the top 6 MSAs when considering original Medicare vs. Medicare Advantage penetration rates, per the chart above. The Chicago MSA has the highest original Medicare rate at just over 70.9% with the lowest Medicare Advantage penetration rate (24.1%). Similarly, Philadelphia is well below the national average with a Medicare Advantage penetration rate of 28.1%.  One reason for the lower Medicare Advantage penetration in both Chicago and Philadelphia is the popularity of Medicare Supplement plans in both Illinois and Pennsylvania. On the other hand, Miami is currently sitting with only 41.5% of those eligible enrolled in original Medicare with the highest penetration rate of the 6 MSAs in the Medicare Advantage market at 53.5%. Los Angeles also records above average Medicare Advantage popularity with almost a 48% penetration rate.
  • Based on MFA’s county estimates, the above table provides the top Medicare Advantage companies and their corresponding market share in each of the top MSAs. UnitedHealth Group appears to have a strong foothold in 5 of the MSAs above, except for the Philadelphia MSA. Humana also has a large presence across the selected MSAs.

Conclusion

Eligibility, geographic location, income levels and overall health status of a population are just a few determinants of Medicare penetration in a particular area.  While further demographic insight would be required to discern why Medicare and Medicare Advantage penetration is higher in some areas more than others, it is clear that the competitive mix among these MSAs indicates varying degrees of consumer choice.  Nonetheless, the Medicare market continues to grow as more and more Americans of the Baby Boom generation enter retirement age.  As always, Mark Farrah Associates will monitor enrollment trends and industry shifts in this highly competitive segment.

 

 

 

Healthcare Triage: Medicare for All and Administrative Costs

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Healthcare Triage: Medicare for All and Administrative Costs

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Political talk is getting more and more serious around Medicare for All in the United States. The argument, as usual comes down to costs. One of the advantages that proponents always bring up are the very low administrative costs of Medicare. Are those low costs for real? Would they hold up if everyone was in the system? Healthcare Triage looks at the facts.

 

 

Dems Won on Health Care. Now What?

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Democrats rode a health care message to their Election Day takeover of the House. Now that the election is (mostly) over, how will they follow through on that campaign focus?

The party is still figuring out its next steps on health care, and Nancy Pelosi and her colleagues will have a lot of decisions to make and details to sort out. “The new House Democratic majority knows what it opposes. They want to stop any further efforts by Republicans or the Trump administration to roll back and undermine the Affordable Care Act or overhaul Medicaid and Medicare,” writes Dylan Scott at Vox. “But Democrats are less certain about an affirmative health care agenda.”

Some big-picture agenda items are clear, though. “The top priorities for Ms. Pelosi, the House Democratic leader, and her party’s new House majority include stabilizing the Affordable Care Act marketplace, controlling prescription drug prices and investigating Trump administration actions that undermine the health care law,” reports Robert Pear in The New York Times.

House Democrats also plan to vote early next year on plans to ensure patients with preexisting medical conditions are protected when shopping for insurance, Pear reports. And they’ll likely vote to join in the defense of the Affordable Care Act and its protections for those with pre-existing conditions against a legal challenge now before a Texas federal court.

Here are a few areas where House Democrats will likely look to exercise their newly won power.

Stabilizing Affordable Care Act markets: “I’m staying as speaker to protect the Affordable Care Act,” Pelosi said in an interview with CBS’s “Face the Nation,” calling that her “main issue.” And Vox’s Scott says that “a bill to stabilize the Obamacare insurance markets would be the obvious first item for the new Democratic majority’s agenda,” adding that a bill put forth by Reps. Richard Neal (MA), Frank Pallone (NJ) and Bobby Scott (VA) is the likely starting point. Democrats may look to provide funding for the Obamacare “cost-sharing reduction” subsidy payments to insurers that President Donald Trump ended in October 2017. And they may look to restore money for Affordable Care Act outreach and enrollment programs after the Trump administration slashed that funding by 84 percent, to $10 million, Pear says. “Another idea is for the federal government to provide money to states to help pay the largest medical claims,” he adds. “Such assistance, which provides insurance for insurance carriers, has proved effective in reducing premiums in Alaska and Minnesota, and several other states will try it next year.”

Investigating the Trump administration ‘sabotage’: “Administration officials who have tried to undo the Affordable Care Act — first by legislation, then by regulation — will find themselves on the defensive, spending far more time answering questions and demands from Congress,” Pear writes.

Reining in prescription drug prices: Trump, Pelosi and Senate Majority Leader Mitch McConnell have all pointed to this as an area of potential cooperation, But Vox’s Scott calls this “another area where Democrats know they want to act but don’t know yet exactly what they can or should do.” Some options include pushing to let Medicare negotiate drug prices directly with manufacturers and requiring makers of brand-name medications to provide samples to manufacturers of generics, potentially speeding the development of less expensive competitors.

“There are a lot of levers to pull to try to reduce drug prices: the patent protections that pharma companies receive for new drugs, the mandated discounts when the government buys drugs for Medicare and Medicaid, existing hurdles to getting generic drugs approved, the tax treatment of drug research and development,” Scott writes. But it’s not clear just what policy mix would really work to bring down drug prices, and the pharmaceutical industry lobby is likely to push back hard on such efforts. Democrats may also be hesitant to give President Trump a high-profile win on the issue ahead of the 2020 election.

Medicare for all: Much of the Democratic Party may be gung-ho for some sort of Medicare-for-all legislation, but don’t expect significant progress over the next two years. “House Democratic leaders probably don’t want to take up such a potentially explosive issue too soon after finally clawing back a modicum of power in Trump’s Washington,” Scott writes. And Democrats have to forge some sort of internal consensus on just what kind of plan they want to push in order to further expand health insurance coverage.

Feds claim Kansas physician involved in $30M billing fraud scheme

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https://www.beckershospitalreview.com/legal-regulatory-issues/feds-claim-kansas-physician-involved-in-30m-billing-fraud-scheme.html

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A Kansas physician and Hutchinson (Kan.) Clinic are defendants in a False Claims Act case the federal government recently intervened in, according to the Great Bend Tribune.

The government alleges Mark Fesen, MD, and Hutchinson Clinic billed Medicare and Tricare for more than $30 million for medically unnecessary medications and treatments, including chemotherapy.

The 45-page federal complaint provides nine examples of patients who received unnecessary treatments.

“These patient examples are not isolated examples, but instead representative examples of the medically unnecessary services Fesen and Hutchinson Clinic repeatedly billed to Medicare and Tricare,” states the complaint. “This is supported by the clinic’s own internal audits that found widespread problems with Fesen’s chemotherapy regimens, and particularly his use of Rituxan.”

A clinical pharmacist who worked in Hutchinson Clinic’s oncology department from 2007-14 originally brought the allegations against Dr. Fesen and the clinic under the qui tam, or whistle-blower, provisions of the False Claims Act.

 

 

Health Care Is on Agenda for New Congress

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https://www.scripps.org/blogs/front-line-leader/posts/6546-ceo-blog-health-care-is-on-agenda-for-new-congress

After months of polls, mailbox fliers, debates and seemingly endless commercials, the mid-term elections are over and the results are in. As predicted by many, the Democrats have won back the majority in the U.S. House of Representatives, while the Republicans have expanded their majority in the Senate.

This means that for the first time since 2015 we have a divided Congress, which leaves me pondering the possible consequences for Scripps Health and the broader health care sector.

Without a doubt, health care will be on the agenda for both parties over the coming months. That became apparent during pre-election campaigning as voters on both sides of the political spectrum voiced concerns about a wide range of health care-related issues.

Exit polls found that about 41 percent of voters listed health care as the top issue facing the country, easily outpacing other issues such as immigration and the economy.

That’s really no surprise. Health care affects all of us, whether we’re young or old, poor or well off, or identify as more conservative or more liberal. And despite all of the division around the country, most Americans seem to agree on at least a few things – health care costs too much, more needs to be done to rein in those costs, everyone should have access to health insurance, and pre-existing condition shouldn’t be a disqualifier for getting coverage.

When the new Congress convenes on Jan. 3, a wide range of health care issues will be on the agenda.

Here are a few of the issues that I’ll be watching as our lawmakers adjust to the reshuffled political dynamics in Washington.

  • Repealing elements of the Affordable Care Act (ACA) is likely off the table now that Democrats control the House. Previously, House Republicans had voted to change a number of ACA provisions that required health insurance policies to cover prescription drugs, mental health care and other “essential” health benefits. But even before the election, Republicans had reassessed making changes to measures that protect people with pre-existing conditions as that issue gained traction with voters.
  • Efforts to expand insurance coverage and achieve universal health care will likely increase. A number of newly elected Democrats vowed to push for a vote on the single-payer option, but other less politically polarizing options such as lowering the eligibility age for Medicare and expanding Medicaid likely will draw more support.
  • While Republicans used their majority in the House to reduce the burden of government regulations in health care and other industries, Democrats might use their new-found power to initiate investigations on a wide range of matters such as prescription drug costs.

We could see some significant changes take place at a more local level as well. On Tuesday, voters in three states approved the expansion of Medicaid, the government program that provides health care coverage for the poor.

And here in California, we will be watching newly elected Governor Gavin Newsom to see what plans he will put forward for expanding health care coverage in this state.

At Scripps, we believe everyone should have access to the health care services that they need, and we have worked hard in recent years to do all that we can to bring down the costs of delivering that care to our patients.

In this new world of divided government, gridlock likely will prevail and President Trump’s initiatives will struggle in the Democrat-controlled House. Everyone will be focused on positioning themselves and their party for the next presidential and congressional elections in two years.

Compromise and bipartisanship are clearly the best options for addressing the health care challenges we now face in ways that have the best chance to win wide public support.

If Democrats in the House fail to reach across the aisle to Republicans or try to make too many changes too quickly, they surely will face many of the same pitfalls that confronted Republicans over the last two years.

 

 

HOSPITALS SHOULD BE BRACING FOR SITE-NEUTRAL PAYMENTS

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https://www.healthleadersmedia.com/finance/hospitals-should-be-bracing-site-neutral-payments

Even if the Trump administration were to delay its proposed site-neutral payments policy for outpatient facilities another year or longer, the political debate isn’t going away.

KEY TAKEAWAYS

Prominent hospital groups have said the rule, as proposed, would be illegal.

Lawmakers from both sides of the aisle in both chambers of Congress have voiced opposition.

Hospitals should do their long-term budgeting and strategizing with site-neutrality in mind.

A controversial proposal to cut reimbursement rates for hospital outpatient departments could be finalized this week if the Centers for Medicare & Medicaid Services hits its target date to publish the final rule.

The proposed change to the Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System unveiled last July has drawn criticism from the American Hospital Association (AHA), America’s Essential Hospitals (AEH), lawmakers in both houses of Congress, and others who contend the so-called “site-neutral” payment policies fail to account for the added burden hospital-owned facilities shoulder.

Both AHA and AEH said in formal comments last month that the OPPS/ASC proposal for 2019 appears to be illegal. And lawmakers raised related concerns in two separate letters to CMS Administrator Seema Verma, suggesting the proposal flouts congressional intent.

A bipartisan group of 48 senators signed a letter last month urging CMS to rethink its approach, and a bipartisan group of 138 representatives followed suit this month with a letter of their own.

The political pressure could very well leave an imprint on the final version of the rule, which has been under review by the Office of Management and Budget since October 10. A spokesperson for CMS told HealthLeaders that the agency would not speculate on the potential outcome of the review process, reiterating the agency’s plan to publish the final version on or about Thursday, November 1.

But even if the Trump administration were to postpone the site-neutral payments policy another year or longer, hospitals should still be preparing for site-neutrality, since this political debate will play itself out over the next several years one way or another, says Greg Hagood, a senior managing director with the financial advisory firm SOLIC Capital.

That preparation for site-neutrality should include an ambulatory strategy with investments in outpatient settings, Hagood said, with a word of caution for hospitals and health systems.

“I think they need to do their budgeting, though, with an eye toward the fact that certain areas that have historically been anchors to the hospital—whether that’s the emergency room, cardiac care, or some of these hospital outpatient departments—are likely to see diminished margins,” he said.

Basing a budget around more-conservative revenue estimates for these service lines could prompt hospitals to rationalize their cost structures or even adjust their infrastructure, such as by reducing their number of clinics or inpatient beds, Hagood said.

Although the concept of site-neutrality “makes a ton of sense” on the surface, there’s also a complex history in how American reimbursement models have evolved over the past few decades, and hospitals provide expensive services that other outpatient facilities often don’t, such as indigent care, Hagood said. Switching to a site-neutral system would have “a very economically disruptive impact on a lot of large health systems,” he added.

The debate gains another layer of intrigue when you consider how any action taken by lawmakers will be perceived by their constituents.

“If you want to make a congressman vulnerable,” Hagood said, “you’ll say he was supportive of a policy that results in a closure of a hospital in your district.”