AMA President Susan R. Bailey, MD, said the "guardrails" for the public option were adopted by the AMA's House of Delegates as part of a broader effort to get more people covered.
The American Medical Association has offered caveat-laden support for some version of a public option health plan that is expected to be brought forward in the coming months when President-elect Joe Biden takes office.
AMA President Susan R. Bailey, MD, said the "guardrails" for the public option were adopted by the AMA's House of Delegates as part of a broader effort to get more people covered.
Specifically, Bailey said, the public option should be available to patients who fall into the "coverage gap" in states that have not expanded their Medicaid rolls under the Affordable Care Act; people who make too much money to qualify for Medicaid, but not enough to afford commercial coverage.
"A public option should not be seen as a panacea to cover the uninsured. It should not be used to replace private insurance; rather it can be used to maximize competition," Bailey said. "With appropriate guardrails, the AMA will examine proposals that would provide additional coverage options to our patients."
The AMA would also support providing financial assistance to buy private or public-option coverage on the ACA Marketplace for people who have access only to otherwise unaffordable employer-sponsored coverage.
The AMA guidelines also call for:
Public-option plans to compete "on an even playing field" with commercial plans.
Payment rates that are "similar" to those of private plans, established through "meaningful negotiations and contracts."
No mandates on physician participation.
Prohibiting federal subsidies for public option plans, which must be "financially self-sustaining."
The AMA's House of Delegates also backed auto-enrollment in Medicaid and CHIP, and in zero-premium ACA marketplace plans for the uninsured who have coverage options available to them at no cost after subsidies are included.
"The AMA believes that now is the time to build upon the ACA to cover more of the uninsured," Bailey said. "We look forward to being at the table to represent physicians and our patients to ensure that our patients are able to secure affordable and meaningful coverage, and access the care that they need."
Whether or not a Biden administration passes a public-option depends largely upon which party controls the Senate in 2021. Republicans oppose the initiative, and if they have the Senate majority, the public option likely won't even be heard in committee.
Assistant Attorney General Jeffrey Bossert Clark of DOJ's Civil Division said the practice of up-coding "undermines the integrity of the program."
"The United States relies on Medicare Advantage Organizations to submit accurate diagnosis data to Medicare to ensure that the compensation they receive is appropriate," he said.
The settlement resolves allegations that the MA plan, formerly known as Group Health Cooperative, brought forward in a whistleblower suit by former employee Teresa Ross, who will get $1.5 million of the recovery money.
Kaiser Responds
Kris Greco Thompson, vice president of public relations, communictions, and brand mamagement, at Kaiser Permanente, said the alleged violations occurred, in 2011 and 2012, before it acquired Group Health Cooperative.
"Kaiser Permanente, which acquired Group Health in 2017 after this investigation was launched and conducted, has a history of commitment to compliance in this area," Greco Thompson said.
"We've fully cooperated with the Department of Justice throughout this entire process and have agreed to a settlement to resolve the outstanding civil claims, as we believe Group Health submitted its data in good faith and in reliance on recommendations by its contracted risk adjustment vendor, which purported to be an expert in this area. Under the settlement, Kaiser Foundation Health Plan of Washington has made no admission of liability and denies the allegations," she said.
Federal regulators say the consolidated health system would reduce competition in the region and raise healthcare costs for consumers.
The Federal Trade Commission is asking a federal court to block Methodist Le Bonheur Healthcare's $350 million acquisition of two Memphis-area hospitals owned by rival Tenet Healthcare Corporation.
In an administrative complaintfiled this weekin the U.S. District Court for the Western District of Tennessee,the FTC alleges that the acquisition of the 519-bed Saint Francis Hospital – Memphis, and 196-bed Saint Francis Hospital – Bartlett "would substantially lessen competition in the Memphis area for a broad range of inpatient medical and surgical diagnostic and treatment services that require an overnight hospital stay, known as inpatient general acute care services, sold to commercial insurers and their insured members."
Four hospital systems now provide acute care services in the Memphis area and the Tenet sale would reduce that number to three and the combined health system would control 60% of the Memphis-area market for general acute care services.
The FTC said that only rival Baptist Memorial Health Care would "meaningfully constrain the combined health system" because the region's fourth system,Regional One Health, is smaller and focuses on a specialized patient mix.
If the acquisition goes through, the FTC said, "healthcare costs will rise, and the incentive to expand service offerings, invest in technology, improve access to care, and focus on quality of health care provided in the Memphis area will diminish."
"Competition between hospitals helps keep prices down and quality high, and that’s as true in Memphis as it is elsewhere," said Daniel Francis, deputy director of the FTC’s Bureau of Competition.
"It's clear that patients in the Memphis area have benefitted from the competitive pressure that Saint Francis brings to bear on Methodist, through lower rates, more options for insurers and patients, and quality improvements. This transaction would take that competition away, and patients will pay the price," he said.
The FTC says the acquisition would eliminate direct competition between Methodist and Tenet, while boosting Methodist's leverage with insurers to negotiate higher reimbursements. Those increased costs, the FTC said, would be passed on to consumers and employer-based health plans.
On a 5-0 vote Friday, the FTC authorize staff to seek a temporary restraining order and preliminary injunction. An administrative trial is scheduled to begin on May 18, 2021.
Tenet and Methodist Le Bonheur Respond
Sally Hurt-Deitch, CEO, of Saint Francis Healthcare, and Michael Ugwueke, president and CEO of Methodist Le Bonheur, issued this joint statement:
"Our joint commitment has always been to improve healthcare delivery for the residents of Memphis, Bartlett and the surrounding communities, including enhancing access to care, cutting-edge medical technology and the highest quality physicians and staff. Our two organizations promote a culture of compassion backed by strong core values, which together, we believe will have an even greater impact on care delivered in these communities."
"We are reviewing this recent action by the FTC and actively considering next steps. We are surprised by the FTC action given the strong support for the transaction by local stakeholders, including leading local health plans, physicians, employers, and community leaders and the evidence that the transaction will lead to lower prices, improved quality, and enhanced access to care for Memphis-area patients."
Medicare will not pay for the monoclonal antibody products that providers receive for free but will reimburse providers for the infusion costs.
Starting immediately, Medicare beneficiaries can get coverage of monoclonal antibodies to treat COVID-19 with no cost-sharing during the public health emergency, the Centers for Medicare and Medicaid Services announced Wednesday.
"Today, CMS is announcing a historic, first-of-its kind policy that drastically expands access to COVID-19 monoclonal antibodies to beneficiaries without cost sharing," CMS Administrator Seema Verma said.
"Our timely approach means beneficiaries can receive these potentially life-saving therapies in a range of settings – such as in a doctor's office, nursing home, infusion centers, as long as safety precautions can be met. This aggressive action and innovative approach will undoubtedly save lives," she said.
CMS said the monoclonal antibody likely will be given to providers at no charge, at least at first.
Medicare will not pay for the monoclonal antibody products that providers receive for free but will reimburse providers for the infusion costs.
When providers start buying the monoclonal antibodies, CMS said it will likely set the payment rate in the same way it set the payment rates for COVID-19 vaccines, such as based on 95% of the average wholesale price for COVID-19 vaccines in many provider settings.
Billing and coding instructions for providers will be issued in the coming days, CMS said.
Verma said today's initiative will allow a range of providers and suppliers to administer the antibody treatment and bill Medicare, including freestanding and hospital-based infusion centers, home health agencies, and nursing homes.
Medicaid
Under section 6008 of the Families First Coronavirus Response Act, state Medicaid programs may receive a temporary 6.2 percentage point increase in the Federal Medical Assistance Percentage through the end of the quarter in which the COVID-19 public health emergency ends.
"A condition for receipt of this enhanced federal match is that a state or territory must cover COVID-19 testing services and treatments, including vaccines and their administration, specialized equipment, and therapies for Medicaid enrollees without cost sharing," CMS said.
"This means that this monoclonal antibody infusion is expected to be covered when furnished to Medicaid beneficiaries, in accordance with the EUA, during this period, with limited exceptions."
Safety experts warn healthcare organizations against using PPE made outside the United States or by non-traditional suppliers.
More than half of disposable isolation gowns tested by ECRI failed to meet protection standards and could expose healthcare workers to dangerous viruses, and bloodborne and other pathogens, the safety research organization said.
The alarming results of the test evaluating 34 models of disposable gowns from foreign or non-traditional suppliers prompted ECRI to issue a high-priority hazard alert to warn healthcare organizations about its safety concerns.
"Hospitals have been ramping up their procurement of isolation gowns to protect workers from the novel coronavirus and we're finding that many of the products they are buying simply do not meet basic protection standards," said ECRI President and CEO Marcus Schabacker, MD.
The warnings come as healthcare providers across the nation are scrambling to acquire persona protective equipment during the coronavirus pandemic.
Non-profit, Pennsylvania-based ECRI found that 52% of gowns it tested with unstated levels of protection failed to meet even the Association for the Advancement of Medical Instrumentation's lowest level for protection.
ECRI also tested gowns that claimed AAMI-level protection and found that 50% did not meet the AAMI PB70 standard for liquid barrier performance. In September, ECRI found that 70% of imported Chinese KN95 respiratory masks it tested failed to meet U.S. standards.
"Our research shows that you can't judge the authenticity of the product based on its appearance, labeling, or packaging without product testing," Schabacker said.
If providers have no other options and must use the substandard PPE, ECRI said they should be used only in low-risk patient encounters or first undergo testing for liquid impact and hydrostatic penetration.
"As we have seen first-hand, manufacturer test reports or certificates are not a guarantee that these gowns are safe and effective," said Michael Argentieri, ECRI's vice president for technology and safety. "We are advising our members against purchasing gowns that do not adequately protect healthcare workers, especially during the pandemic."
Payers and providers alike predict havoc and a public health crisis if the U.S. Supreme Court strikes down the Affordable Care Act.
The future of the Affordable Care Act may be in jeopardy as the U.S. Supreme Court on Tuesday heard oral arguments calling for its elimination, but healthcare stakeholders are united in their support of the landmark law.
Here's a sampling of what they had to say.
Sr. Mary Haddad, RSM, President and CEO, Catholic Health Association of the United States
"Striking down the ACA would be devastating to the approximately 20 million Americans who gained coverage under the law, including 15 million low-income individuals who are covered by Medicaid Expansion. It would adversely impact the approximately 130 million Americans with pre-existing medical conditions, including those diagnosed with COVID-19. The pain of repeal would be borne by some of the most vulnerable in our society – pregnant women, racial minorities, and low-income individuals and families."
"Our members witness firsthand the devastating impact that a lack of affordable health insurance and healthcare has on individuals, families, and communities, especially during the pandemic. The uninsured often do not seek out the care they need and may suffer unnecessarily if their illness or injury gets worse."
"If the Supreme Court strikes down the entire ACA, it would wreak havoc on the U.S. healthcare system and irreparably harm those most in need of care. We strongly urge the Court to rule that the individual mandate is severable, as clearly intended by Congress when it eliminated the individual mandate penalty but did not repeal the entire ACA."
Chip Kahn, President and CEO, Federation of American Hospitals
"It is imperative that the Supreme Court uphold the ACA. Tens of millions of Americans depend on health coverage and protections provided by the law. In the midst of COVID is no time to let down the millions who we serve as our patients."
"As caregivers, the goal of hospitals for our patients is to see increased access to affordable coverage for all Americans - not new obstacles. The ACA framework can accomplish this goal. We hope the Supreme Court will see its way clear to allow it to go forward."
Jacqueline W. Fincher, MD, MACPPresident, American College of Physicians
"We all need to understand the damage that would be done to healthcare for Americans if the law is thrown out. Since the ACA was signed into law over a decade ago, it has become critical to the functioning of the U.S. healthcare system. The ACA provides access to affordable health coverage for millions of Americans. It ensures that health insurance covers essential benefits and that effective preventive healthcare is fully covered. It ensures no one has to pay more for coverage, or is prevented from getting it, because of their age, gender, occupation or health condition."
"Our healthcare system is already under unprecedented strain due to the COVID-19 pandemic. If the ACA were to be thrown out at the same time that we face the pandemic, it would cause chaos for physicians and our patients, and for the entire healthcare system. Millions of Americans who have been infected by the coronavirus could now have their coverage in jeopardy if protections for pre-existing conditions were no longer in place. Millions of Americans have lost or are in danger of losing their employer-sponsored insurance and will need coverage through the ACA's health insurance marketplaces or Medicaid expansion."
Ada D. Stewart, MD, President, American Academy of Family Physicians
"With the current health crisis, there are projections that the number of Americans with pre-existing conditions will grow significantly as people suffer long-term effects of COVID-19. It is more important than ever that we ensure these protections and affordable access to coverage remain in place."
“The ACA has contributed to the forward progress of the healthcare system including recognizing the need to train a more robust primary care workforce through the Teaching Health Center Graduate Medical Education Program and has encouraged innovation through the creation of the Center for Medicare and Medicaid Innovation."
America's Health Insurance Plans
"We are encouraged by the thoughtful questions raised by the Justices in today's arguments and are confident that the Court will come to the right decision to uphold the law and sustain the ACA's important consumer protections. Invalidating the law would be misguided and wrong and unleash chaos on the entire healthcare system. For Americans with pre-existing conditions, worrying about their health can be constant. Worrying about whether they will have coverage for their health conditions should not be."
"Health insurance providers are united in their commitment to the ACA and its protections for Americans with pre-existing conditions. Regardless of your health, you should have the peace of mind of knowing that your health status will not result in your being charged more than others for your major medical coverage."
Scott P. Serota, President and CEO, Blue Cross Blue Shield
"The U.S. Supreme Court should not invalidate the Affordable Care Act. To do so would strip vital protections from consumers no matter where they get their health insurance coverage – through an employer, Medicare and Medicaid, or the individual marketplaces that were created under the law." "The ACA is particularly critical now for millions of the newly unemployed and their families, ensuring they still have access to quality and affordable health insurance coverage during a severe public health crisis."
Charlotte Haberaecker, President and CEO, Lutheran Services in America.
“While the ACA is not perfect, the protections it has instituted for underserved groups have greatly increased their ability to access much-needed health care especially important during the ongoing COVID-19 public health emergency."
"At this vital time, given our longtime commitment as a faith-based organization to meeting the health and human services needs of all people, we urge Congress and the Administration to safeguard in federal law protections for these populations throughout America."
Margaret A. Murray, CEO, Association for Community Affiliated Plans
"Even if the Court were to ultimately hold the individual mandate to be unconstitutional, it requires a strained reading to strike down the law of its entirety. It would also require a strained interpretation of the plain actions of Congress, which chose to remove the enforcement mechanism for the individual mandate but left in place the mandate itself – and the remainder of the ACA."
CMS Administrator Seema Verma says the rule strikes a balance between federal oversight and state flexibility.
The Centers for Medicare & Medicaid Services on Monday released the 2020 Medicaid and Children's Health Insurance Program Managed Care final rule.
CMS Administrator Seema Verma said the final rule cuts red tape and lowers federal regulatory barriers, which allows state Medicaid and CHIP agencies to customize managed care programs for the 55 million beneficiaries – including 79% of CHIP children in 32 states – who are enrolled in Medicaid managed care programs.
"The era of prescriptive regulations has failed. This rule represents a concerted effort to transform Medicaid to improve quality and access for its beneficiaries," Verma said.
Verma said a working group of stakeholders, including the National Association of Medicaid Directors, helped to craft the final rule, which removes some of provisions in the 2016 final rule that stakeholders had complained were overly prescriptive and burdensome.
"This will remove the burden on states while ensuring appropriate oversight of managed care organizations," she said. "The government should identify expected outcomes, results, and standards – not micromanage processes."
Under the final rule, CMS will provide guidelines for states to complete the federal rate review process, while preserving the requirement for states to implement a Quality Rating System for the managed care plans they contract with, CMS said.
The rule also bolsters efforts to provide access and quality care to rural beneficiaries by changing the minimum standards for network adequacy to support state adoption of telehealth.
Most of the provisions take effect 30 days after the Final Rule is issued Nov. 13.
The rule, mandated under a June 2019 executive order by President Donald Trump, requires private group health plans and individual health insurance market plans to disclose pricing and cost-sharing information in a consumer-friendly format.
The mandate, which takes effect on January 1, 2021, has drawn the ire of payers and providers because of a key provision that health insurance companies must publicly disclose "in real time" the rates they pay providers for specific services.
The American Hospital Association this summer led an unsuccessful effort by providers to ask a federal court to nullify the final rule, arguing, among other things, that the final rule is "arbitrary and capricious," and that the requirement that hospitals publish negotiated rates with insurers violates the First Amendment and oversteps the government's legal authority. The plaintiffs have appealed the ruling.
"The proposal does nothing to help patients understand their out-of-pockets costs," AHA General Counsel Melinda Hatton said at the time. "It also imposes significant burdens on hospitals at a time when resources are stretched thin and need to be devoted to patient care."
Matt Eyles, president and CEO of America's Health Insurance Plans, on Thursday called the final rule "flawed" and predicted it would "reduce competition and push healthcare prices higher – not lower – for American families, patients, and taxpayers."
"This is precisely the opposite of what Americans want in their healthcare," Eyles said. "Competition experts, including the bipartisan Federal Trade Commission, agree that disclosing privately negotiated rates will reduce incentives to offer lower rates, creating a floor – not a ceiling – for the prices that drug makers, providers, and device makers would be willing to accept."
The mandate also requires payers to provide personalized estimates of patients' out-of-pocket cost for 500 of the "most shoppable items and services," along with the costs for the remaining procedures, drugs, durable medical equipment and any other item or service they may need, the Centers for Medicare & Medicaid Services said.
CMS Administrator Seema Verma on Thursday called the final rule "perhaps the most consequential healthcare reform in the last several decades," which "will allow for unprecedented price transparency that will benefit employers, providers, and patients to help drive down healthcare costs."
"Price transparency puts patients in control and supports competition on the basis of cost and quality which can rein in the high cost of care," she said.
Original Medicare and Medicare Advantage beneficiaries will get the vaccine at no cost.
The federal government on Wednesday laid the groundwork for funding and distribution of an eventual coronavirus vaccine that policymakers say will allow providers, states, and payers to "act swiftly" when a treatment becomes available.
The interim final rule released by the Centers for Medicare & Medicaid Services mandates that any vaccine that receives Food and Drug Administration approval will be covered under Medicare as a preventive vaccine at no cost to beneficiaries.
"The rule removes any existing ambiguity surrounding Medicare's coverage to the COVID-19 vaccine," CMS Administrator Seema Verma said Wednesday.
"(This) allows us to focus on the paramount goal of ensuring that all of Medicare 62 million beneficiaries, including those enrolled in a Medicare Advantage plan can receive the vaccine at the provider of their choice again, at no cost."
"And while the federal government is paying for the vaccine, insurers including Medicare, Medicaid and private plans must cover the cost of administering it," Verma said.
"If you're in Medicare Advantage, providers are just going to build a traditional program and essentially beneficiaries can go wherever they want to whatever provider to get their vaccine," Verma said.
Under the final rule, Medicare will pay $28.39 to administer single-dose vaccines, and $16.94, and $28.39 for a vaccine requiring two or more doses. These rates will be adjusted for geography and will take into consideration administrative costs, public outreach, patient education, and reporting requirements.
Verma estimated the cost at about $2.6 billion "if everybody got vaccinated in the Medicare program."
"And obviously, with Medicaid and the private insurance companies, it depends on how much they're going to reimburse for the administration of the vaccines. The federal government is covering the cost of the actual vaccine," she said.
CMS is recommending that state Medicaid programs and commercial payers use the Medicare reimbursement as a benchmark in their vaccine payment plans.
"Using the Medicare strategy as a model would allow states to match federal efforts in successfully administering the full vaccine to the most vulnerable populations," CMS said.
CMS also activated CARES Act provisions that mandate vaccine coverage by most commercial payers with no cost sharing for both in-network and out-of-network providers during the public health emergency.
Therapies
The interim final rule creates additional and automatic Medicare hospital payments for authorized COVID-19 therapies during the public health emergency to mitigate potential losses incurred to make the therapies available, and includes reimbursements for outpatient treatments outside of bundled arrangements and are paid separately.
Verma said the interim final rule on therapies "will eliminate financial disincentives that hospitals may face for furnishing potentially life-saving treatments to America's seniors."
"Traditionally, when a hospital costs for a particular patient exceeds Medicare payments, the hospital can qualify for additional outlier payments, but only after their costs exceed a threshold of about $30,000," Verma said.
"Under this rule, Medicare will pay an additional 65% of the cost for innovative COVID therapies authorized by the FDA provided in an inpatient hospital setting when treatment costs exceed the Medicare payments up to that $30,000 threshold," she said.
If a hospital's costs exceed the threshold, Verma said, they can still qualify for the traditional outlier payments.
"In short, we are bridging the gap between the standard payment and the outlier payments," she said.
Willis Towers Watson finds that while nearly half of employees are deferring medical care, few report suffering worse health outcomes so far.
Workers have embraced telehealth during the coronavirus pandemic and they are giving the virtual care experience high marks, a Willis Tower Watson survey finds.
Almost half of respondents in the survey (47%) have used virtual care services this year — almost three times more than last year (17%), the survey found.
The employees also gave virtual care high marks compared with face-to-face consultations, with 79% reporting virtual care as good, and 25% rating it better. Nearly 80% employees said they would consider using virtual care in the future.
"Virtual care turned out to be just what the doctor ordered during the pandemic," says Julie Stone, WTW's managing director, Health and Benefits.
"Employers were quick to expand and educate employees on how to access virtual care, and employees — especially those who were hesitant to access traditional medical care — took advantage of it," Stone says. "While most employees used virtual care for regular screenings and checkups, a significant number were able to utilize it for diagnosis and treatment of a new illness, chronic conditions and importantly, mental health services."
However, the survey of nearly 5,000 U.S. employees by the Arlington, Virginia-based consultants also found that nearly half of respondents have deferred medical care since the start of the pandemic, primarily over COVID-19 and money concerns.
The 2020 Global Benefits Attitudes Survey also found that:
44% have deferred medical care during the pandemic with 30% either cancelling or postponing a treatment or appointment; 25% said their medical provider has cancelled or postponed a treatment or appointment.
61% said they are worries about COVID-19 for deferring care; 42% cited money concerns.
29% of employees who have deferred care said their health suffered as a result of cancelling an appointment or treatment, while 40% expect their health will suffer.
26% said they will increase their healthcare use when the pandemic ends. 53% with a chronic condition who deferred care expect to significantly increase their use of healthcare services when the pandemic ends.
One in three employees have used virtual care for regular screening and checkups. One in five have used virtual care for mental healthcare or treatment for a new illness.
Virtual care has opened additional pathways for employees to access care, especially for low-income employees, who are more than 40% more likely to say they got the care they needed when using virtual care.
15% reported their physical health had declined due to the pandemic. 22% said their physical health had improved, while 63% indicated no change.
29% said their mental/emotional health had worsened; 53% indicated there was no change, and 18% reported an improvement.
More employees reported improvements than declines in their lifestyle habits (26% versus 23%) and work/life balance (27% versus 21%); however, 42% said their social connections had worsened.
