Judge Reed O'Connor deemed the services unconstitutional, drawing heavy criticism from patient advocacy groups.
A key piece of the Affordable Care Act (ACA) requiring employers to cover an HIV prevention drug and other preventive services is in jeopardy after a federal judge ruled against it for violating religious freedom.
Judge Reed O'Connor of the U.S. District Court for the Northern District of Texas ruled in favor of Steven Hotze, owner of Braidwood Management, who claimed the ACA mandate violates the Religious Freedom Restoration Act.
Hotze specifically took issue with being forced to buy health insurance for his employees to cover an HIV prevention drug, preexposure prophylaxis (PrEP), arguing it "facilitates and encourages homosexual behavior, intravenous drug use, and sexual activity outside of marriage between one man and one woman," the ruling stated.
O'Connor wrote that "Braidwood has shown that the PrEP mandate substantially burdens its religious exercise."
Additionally, O'Connor found that the U.S. Preventive Services Task Force violates the Constitution's Appointments Clause, which deems how public officials are appointed, because of the scope of the task force's authority.
O'Connor previously ruled that the entire ACA was unconstitutional in 2018, arguing that the law was invalid because Congress zeroed out the penalty tied to its individual mandate. The decision was flipped by the Supreme Court, which upheld the ACA by a 7-2 vote in 2021 in the midst of the COVID-19 pandemic, allowing millions to retain their insurance coverage.
Patient advocacy groups have spoken out against O'Connor's most recent ruling, voicing their displeasure and warning of the dangers of the decision.
"The free preventive care guaranteed by the ACA has become a bedrock of our health care system, benefiting patients with all types of insurance, including those insured by their employer," Protect Our Care chair Leslie Dach said in a statement. "The consequences of this ruling cannot be understated and it is essential that Judge O'Connor stay the effects of his order while this disastrous decision is appealed."
The Medical Group Management Association (MGMA) and the American Hospital Association (AHA) have offered their recommendations on streamlining the administrative process.
Reforming prior authorization to cut down on treatment delays and administrative burden is a necessity for improving Medicare Advantage (MA), according to key medical groups.
MGMA and AHA have submitted their comments to CMS in response to a request for information on the MA program, with both groups offering recommendations on prior authorization policies.
Publish the Interoperability and Prior Authorization for MA Organizations, Medicaid and CHIP Managed Care and State Agencies, FFE QHP Issuers, MIPS Eligible Clinicians, Eligible Hospitals and CAHs proposed rule: This rule would improve the electronic exchange of data and streamline prior authorization processes, but MGMA believes the timeframe for when health plans should respond to medical groups for urgent prior authorizations and for standard prior authorizations should be shorter than the timeframe CMS proposed of 72 hours and seven days, respectively.
Implement recommendations included in the OIG report: The research revealed the MA organizations often unnecessarily delayed or denied members' access to services, even when prior authorization requests met coverage rules. Among its recommendations, OIG urged CMS to update audit protocols to prevent errors.
Reinstate step therapy prohibitions in MA plans for Part B drugs: MGMA notes that step therapy requires patients to try and fail certain treatments before allowing access to usually more expensive treatments, which allows health plans to undercut the provider-patient decision-making process.
Increase CMS oversight over MA plans' use of prior authorization processes.
Require transparency of payer prior authorization policies and establish evidence-based clinical guidelines available at the point of care.
Requires MAOs to follow traditional Medicare coverage rules to prevent unnecessary delays and burdens associated with inappropriate use of prior authorization.
Establish a standard electronic transaction for providers to submit and receive responses for prior authorizations.
Improve the quality and use of MAO data related to prior authorizations, including changes in the frequency of reporting, increased transparency, penalties for non-compliance, more targeted auditing, and suggestions for how these data could be incorporated into Star Ratings.
Reduce administrative waste in the MA program, including requiring plans to comply with standard, electronic process for prior authorization.
While prior authorization requirements can negatively affect patient outcomes, as shown in the OIG report, the administrative process can also hinder providers.
A recent survey by MGMA revealed that 79% of medical groups feel that payer prior authorization requirements increased in the past year. The increase is only putting more stress on providers, with 88% of physicians reporting that the administrative burden associated with prior authorization is high or extremely high, according to a survey conducted by the American Medical Association.
The federal agency is striving to make it easier for eligible people to enroll in and continue their Medicaid coverage.
The Biden administration has proposed a new rule to overhaul the application and renewal process for Medicaid and other government programs like the Children's Health Insurance Program (CHIP), CMS announced.
By simplifying enrollment and verification processes, CMS is aiming to make it easier for children, older adults, and people with lower income to both attain and retain Medicaid and CHIP coverage.
With the COVID-19 public health emergency slated to end on October 13, the proposed rule comes at a time when states are beginning to notify Medicaid beneficiaries about potentially losing coverage.
The proposal includes standardizing eligibility and enrolment policies like limiting renewals to once every 12 months to allow applicants 30 days to respond to information requests.
It would also end lifetime benefit limits in CHIP, allowing children to enroll in coverage immediately by doing away with pre-enrollment waiting periods. Children's eligibility would transfer directly from Medicaid to CHIP when a family's income rises, preventing an unnecessary redetermination process.
For adults aged 65 and older, as well as those with a disability, the proposed rule would remove unnecessary administrative hurdles for individuals who are eligible for the government programs.
"This proposed rule will ensure that these individuals and families, often from underserved communities, can access the health care and coverage to which they are entitled – a foundational principle of health equity," CMS administrator Chiquita Brooks-LaSure said in a statement.
Other changes in the proposal include:
Establish a clear process to prevent termination of eligible beneficiaries who should be transitioned between Medicaid and CHIP when their income changes or when the beneficiary appears to be eligible for the other program, even when the beneficiary fails to respond to a request for information.
Ensure automatic enrollment, with limited exceptions, of Supplemental Security Income recipients into the Qualified Medicare Beneficiary group.
Eliminate the requirement to apply for other benefits as a condition of Medicaid eligibility to ensure eligible individuals to reduce unnecessary administrative hurdles.
Propose specific timelines for states to complete Medicaid and CHIP renewals, including guidelines to ensure beneficiaries who return information late are properly evaluated for other eligibility groups prior to being terminated.
The median revenue amount from value-based contracts across all practices was $30,922 per provider in 2021.
Even with the healthcare industry trending towards more value-based care, the transition away from fee-for-service is happening at a slow rate.
Medical revenue continues to predominantly consist of fee-for-service payments, with value-based care making up just a small slice, according to a report by the Medical Group Management Association(MGMA).
The survey found that revenue from value-based contracts accounted for 6.74% of revenue in primary care specialities, 5.54% in surgical specialities, and 14.74% in nonsurgical specialities. Across all practices, the median revenue amount from value-based contracts was $30,922 per full time equivalent provider.
MGMA examined 2021 data from more than 2,300 organizations from a variety of specialties and practice types to gauge the shift to value-based reimbursement.
The research also revealed that the share of physician compensation tied to quality performance has changed during the pandemic. More than a third (35%) of medical groups report they have increased the share of compensation tied to quality in the past two years, while 62% said they have the same share compared to 2019. Only 2% of respondents said they have decreased the percentage of compensation tied to quality.
The workforce shortage has had an affect on appointments, the survey stated, with appointment availability for new patients increasing by two days, from 6.1 days in 2020 to 8.1 days in 2021.
While no-show rates held steady, appointment cancelations also increased across nonsurgical and surgical specialties, jumping from 8.3% in 2020 to 17.7% in 2021, and from 7.0% to 8.4%, respectively. Primary care experienced a slight decline in cancelations from 8.3% to 8.0%.
Practices reported that it took longer to post charges in 2021 for third-party payment from the time a patient is seen. Primary care saw a dip in charge-positing lag time from 5.2 days in 2020 to five days in 2021, but nonsurgical and surgical specialties jumped significantly, from 6.8 to 11.6, and from 6.8 to 10.4, respectively.
The number of claims denied on first submission also rose in 2021, across all specialty types. Primary care saw an increase from 4% to 8%, nonsurgical went up from 3% to 8.14%, and surgical leapt from 4.16% to 8.14%.
However, percent of copayments collected at the time of service decreased across the board.
With the stress that's placed on the dwindling number of staff, optimizing administrative operations is key to alleviating the challenges practices are facing today.
"The medical workforce is grappling with burnout, staffing declines, decades-high inflation, operational challenges and a dynamic reimbursement environment that affects providers across the board," Halee Fischer-Wright, president and chief executive officer of MGMA, said in a statement.
"This report reveals how addressing scheduling errors and billing denials could help relieve the financial burden on health groups, moving them toward value-based care that promotes the welfare of physicians, staff, and patients."
Nearly one-third of patients with seven or more chronic diseases face medical debt versus 7.6% for individuals with no chronic conditions.
Patients with chronic conditions have a higher likelihood of facing adverse financial outcomes and incurring medical debt, according to study published in JAMA Internal Medicine.
The research used medical claims data from adults enrolled in Blue Cross Blue Shield of Michigan from January 2019 to January 2021 and linked it to commercial credit data in January 2021.
Of the 2.85 million adults studied, the predicted probabilities of having medical debt, nonmedical debt, delinquent debt, a low credit score, or recent bankruptcy were all significantly higher when more chronic conditions were present.
Individuals with seven to 13 chronic diseases had medical debt 32% of the time, compared to 7.6% for those with none. The split between the two groups was also wide and skewed heavily to adults with seven or more chronic conditions when it came to nonmedical debt (24% vs 7.2%), delinquent debt (43% vs 14%), a low credit score (47% to 17%), and recent bankruptcy (1.7% vs 0.4%).
Among those with medical debt, the estimated amount increased with the number of chronic conditions, from $784 for individuals with no chronic conditions to $1,252 for those with seven or more.
The findings featured sizeable variation between each chronic condition and its risk of creating medical debt. The chronic conditions associated with the greatest adjusted increases in medical debt were severe mental illness ($274), substance use disorders ($268), stroke ($235), congestive heart failure ($234), and liver diseases ($228).
The study notes that the variation between conditions could suggest some conditions are more costly to treat with higher out-of-pocket expenses, while others may lead to an individual's inability to work and earn income.
Regardless, the results of the research show that worsened financial health is associated with worse physical and mental health outcomes.
"If poor financial well-being leads to additional chronic disease, policy makers should consider new social safety-net policies to reduce poverty rates and should explicitly incorporate improvements in physical health—and correspondingly reduced health care spending—as a benefit of antipoverty programs," the study concluded.
"If, in contrast, chronic disease diagnoses are directly leading to adverse financial outcomes, then improving commercial insurance benefit design would be warranted to provide additional protection from out-of-pocket medical expenses, particularly for conditions identified as being costly for patients."
The implications of patients accumulating debt puts stress on providers as well.
Accountable Care Organizations (ACOs) are delivering high-quality care while spending less to earn performance payments.
The Medicare Shared Savings Program saved $1.66 billion in 2021 compared to spending targets, CMS announced today.
It marks the fifth consecutive year savings have been generated by the program, which worked with ACOs to incentivize the delivering of high-quality care.
ACOs are made up of various providers who come together to give value-based care to Medicare patients. When an ACO can both deliver high-quality care and spend wisely by avoiding unnecessary services, they can qualify to share in the savings they've created for the program.
As of January 2022, Shared Savings Programs include over 525,000 providers giving care to more than 11 million Medicare beneficiaries, according to CMS. The federal agency is aiming to have 100% of people with traditional Medicare in an accountable care relationship by 2023.
"The Medicare Shared Savings Program demonstrates how a coordinated care approach can improve quality and outcomes for people with Medicare while also reducing costs for the entire health system," CMS administrator Chiquita Brooks-LaSure said in a statement. "Accountable Care Organizations are a true Affordable Care Act success story, and it is inspiring to see the results year after year. The Biden-Harris Administration and CMS are committed to a health care system that delivers high-quality affordable, equitable, person-centered care – and a Medicare program that can deliver just that."
CMS states that approximately 58% of participating ACOs earned payments for their performance in 2021, with low-revenue ACOs leading the way at $237 per capita in net savings, compared to $124 for high-revenue ACOs. The ACOs made up of at least 75% primary care clinicians saw $281 per capita in net savings, compared to $149 for ACOs with fewer primary providers, highlighting the importance of primary care to the success of the Shared Savings Program.
The program is also facing potential changes after CMS outlined its proposed 2023 Physician Fee Schedule, which features expanding access to ACOs.
The proposal includes incorporating advance payments to certain new ACOs in rural and underserved communities, allowing smaller ACOs to progress more slowly from low to high risk, benchmark adjustments to encourage more ACO participation, and more. Public comments on the Physician Fee Schedule are due by September 6.
The National Association of Accountable Care Organizations (NAACOS) has backed the potential changes to the program and lauded ACOs role in creating significant savings last year.
"Today's results again demonstrates that ACOs drive us towards a health care system that delivers affordable, equitable, high-quality, person-centered care" Clif Gaus, NAACOS president and CEO, said in a statement. "Eight years of continued strong performance with the positive proposed changes to the program included in the physician fee schedule sets the stage for significant growth in accountable care."
Medical claims are back on the rise after being supressed during the early stages of the COVID-19 pandemic.
Healthcare costs for employers are set to increase to more than $13,800 per employee in 2023, according to analysis by Aon.
The financial services firm used data of nearly 700 employers representing approximately 5.6 million employees and found that healthcare expenditures will rise significantly from the budgeted $13,020 per employee in 2022.
The projection of a 6.5% increase is more than double the rate employers experienced from 2021 to 2022, but remains well below the 9.1 inflation figure reported through the Consumer Price Index, the research stated.
Naturally, with employees utilizing care more at typical levels following the first year of the COVID-19 pandemic, medical claims have increased and continue to grow.
Inflation will affect costs, as will other factors like new technologies, severity of catastrophic claims, blockbuster drugs, and increasing share of specialty drugs, Aon notes.
When it comes to health plans, the research revealed employer costs shot up by 3.7% in 2022, while employee premiums from paychecks rose by 0.6%.
"In what remains a tight labor market, employers are absorbing most of the health care cost increases," Debbie Ashford, the North America chief actuary for health solutions at Aon, said in a statement. "Employers are budgeting higher due to uncertainty and the anticipation that inflationary pressures will increase the cost of health care services."
One approach to alleviate high costs is to target patients with chronic and complex conditions, the analysis states. Ashford notes it is not uncommon to see 1% of membership making up 40% of spending in a given year.
By identifying and predicting when costs associated with long-term complex conditions can arise, employers can find solutions to spending.
"The effect of chronic conditions has far-reaching implications beyond what we see with health care costs, out to the other areas of the business, like absence and productivity, disability and worker's compensation," said Farheen Dam, Aon's North America health solutions leader. "By focusing on chronic conditions, not only are we improving the health and happiness of employees, but we're helping to improve the way they live and work."
The updates in CMS' proposed rule would slash Medicare payments to home health agencies by $810 million in 2023.
The American Hospital Association (AHA) and the Partnership for Quality Home Healthcare (PQHH) have expressed concern to CMS regarding the Calendar Year (CY) 2023 Home Health Prospective Payment System Rate Update, arguing the proposed cut is steep and technically flawed.
In their respective written letters to the federal agency, the groups advised reconsideration for the market basket update which would decrease Medicare payments to home health agencies by $810 million in 2023.
Under the proposed Patient-Drive Groupings Model (PDGM) behavioural offset, an offset of 7.69% to the 30-day payment rate for CY 2023 will be applied in addition to the original offset of 4.36% in CY 2020. CMS states that the additional offset ensures PDGM budget neutrality, but AHA argues that it fails to account for the drop in average per-episode therapy services.
"As such, we urge CMS not to finalize any budget neutrality adjustment for CY 2023," AHA writes. "Instead, we ask the agency to reevaluate its PDGM budget neutrality methodology to account for the drop in therapy in CY 2020 and subsequent years. Doing so could substantially reduce or negate the need for any behavioral offset, or actually create the need for a future restoration of funds."
PQHH, meanwhile, decries CMS' implementation of the PDGM, pointing to the negative effects on patients and quality of care.
"The payment reductions proposed in this rule conflict with the law and will be disastrous for patient access and care delivery and will undermine CMS’ broader goals to advance health equity and quality improvement," PQHH writes.
The groups take issue with the market basket increase of 3.3% minus a 0.4% productivity adjustment. The proposed permanent adjustment to the -7.69% results in a decrease in payments of 4.2%, or $810 million lost.
PQHH highlight the many challenges facing home health facilities and how the increase to the proposed payment rates doesn't reflect the increase in costs during the COVID-19 pandemic.
"Currently, well-documented staffing shortages and dramatic increases in the cost of labor, fuel, medical supplies, and other resources necessary to deliver care have created challenges for home health providers," PQHH write. "We are concerned that annual increases to the home health payment rates based on the current market basket have not kept pace with recent cost increases. The significant increase in such costs adds to financial pressure on providers already facing numerous challenges and impacts access to care for patients."
The federal agency's informational bulletin details methods for improving safety and quality of care for nursing facilities.
As part of the Biden administration's efforts to reform nursing homes, CMS is encouraging states to tie Medicaid payments to quality measures to advance health equity and improve patient outcomes.
The federal agency's Centers for Medicaid and CHIP Services issued an informational bulletinfor states outlining actions to drive better health outcomes for nursing home residents while strengthening staff pay, training, and retention efforts.
In February, the Biden administration announced a set of reforms to improve nursing homes by addressing safety and quality of care. The reforms aim to ensure that every nursing home provides adequate staffing, poorly performing nursing homes are held accountable for improper and unsafe care, and that the public has better information about nursing home conditions so they can opt for the best option.
By tying nursing home Medicaid payments to quality measures, CMS is further incentivizing advancing health equity by shifting the focus from volume to quality through value-based payments. The agency also notes that as of 2019, 2 million Medicaid beneficiaries received institutional services.
"Today's action is an important step toward accomplishing the administration's goals of strengthening the quality of care, accountability, and transparency in our country's nursing homes for Medicaid enrollees. States can implement a number of initiatives described in this guidance immediately," CMS administrator Chiquita Brooks-LaSure said in a statement.
"Medicaid enrollees residing in nursing homes will only experience better care through collaboration between states, CMS, providers, and other partners, and we look forward to working closely with them on this important effort."
CMS highlights how states can implement actions using flexibilities provided by the Social Security Act to establish Medicaid base and supplemental payments to provide performance-driven nursing home rates. Through the Medicaid state plan, waiver, or demonstration process, states can immediately implement initiatives to give Medicaid beneficiaries in nursing homes better care.
The agency also encourages states to align with initiatives such as the Nursing Home Five-Star Quality Rating System by improving safety, accountability, quality, and overall resident experience. The System is based on six measures, including weekend staffing rates for nurses and turnover of nurses and administrators over the course of the year.
"We know that low wages for staff can contribute to frequent turnover and dangerous staffing shortages at nursing homes, so we encourage states to work with these facilities to find solutions for training and improving staffing."
The potential impact is considered "relatively modest" as the industry is better positioned than it was during the 2008 recession.
Slowing economic growth and inflation are the most likely hurdles to trip up health insurers going forward, but their impact on the industry shouldn't be severe, according to Moody's Investors Service.
The August economic reportanalyzes the biggest challenges to sectors of healthcare and when it comes to payers, Moody's notes that supply chain issues, higher interest rates, and the labor shortage are secondary concerns.
A slowing economy, however, threatens to curb commercial enrollment if jobs are lost. For example, Moody's cites that in 2020 during the early stages of the COVID-19 pandemic, commercial membership fell by 2.7 million, or 2.4%. An increase of 5 million in Medicaid membership offset the enrollment decline.
Government programs like Medicaid and Medicare Advantage claim a much bigger slice of the pie than they did in 2008, and that, along with more portfolio diversity, should protect payers better in an economic downturn today.
One issue that insurers are still susceptible to is rising costs through increased claims if commercially-insured individuals once again accelerate utilization of care due to the fear of being laid off, as they did in 2008.
Inflation, meanwhile, has the potential to be a problem for payers if it's long term, lasting two year or more. Moody's states that persistent inflation could lead to providers demanding higher commercial reimbursement, which insurers might not be able to recoup through higher premiums for members. If commercial premiums exceed the rate of inflation, small businesses with less than 50 employees could drop coverage as they're not required to provide insurance.
"Therefore, inflation could indirectly put downward pressure on commercial enrollment, a key driver of earnings for the industry. In a scenario that features both higher unemployment and inflation, there could be intensified pressure on commercial enrollment," Moody's concludes.
Payer executives have their own ideas as to what their top challenges are, according to a survey from HealthEdge. More than 300 respondents identified managing costs and operational efficiencies as the biggest priorities for health plans today.
Those obstacles ranked fourth and fifth, respectively, in the previous survey for 2021, with the change in rankings attributed to an increase in claims volume after the pandemic, rising costs due to delays in care, and outdated administrative systems.
While payers are somewhat insulated from economic pressures, at least in comparison to other areas in healthcare, the industry has its own set of challenges to navigate.
