March 1, 2013 Legislation




Be careful what you wish for.  It may come true.  The head of MedPAC has pushed Congress to get rid of the SGR by moving away from fee for service to something that is more subjective and can be lowered easier.  He wants more parity between primary and specialty care as well as movement toward new payment models.  The Urban Institute gave caution to Congress at the hearing that there is no uniform quality based measures now in place in which to determine what is quality or adequate performance measures.  Some have suggested a five year transition period between the end of fee for service and whatever takes it place.

Dr. Richard Wilner sent me the next item from The Advisory Group.  The article states that in the Fiscal Cliff (Slope) negotiations the providers were screwed again.  The provider audits by CMS (RAC) were changed from a look back of three to five years from the date of payment.  On the good side this may change the Medicare preliminary ten year look back to what will be five years in the final edition.

Thank you Obama.  He has decided that states increasing their Medicaid is more important than anyone seeing the patients.  He has ordered that the feds back California's attempt to decrease by 10% the payments to hospitals and physicians.  This will cause any physician that sees Medicaid patients in the state to stop seeing them.  It may also stop hospitals from contracting with the program for their elective patients. The law which the administration conveniently wants to ignore is that Medicaid must pay enough to make sure there are adequate providers to see the patients.  When the law interferes with politics, politics win.

Well the time has passed and the answer is in.  The Feds will run half of all the state exchanges starting in 2014.  This means that they along with the 20 states that will do their own and the six states that will do it with the feds will have to get their act in place by October of this year.  This is unlikely in all avenues.  This is especially true for the feds who can not even tie their own shoes in that period of time.

The administration has now decreed that the removal of precancerous polyps in Medicare patients undergoing a "free" colonoscopy is considered part of the procedure and the patient can not be charged for it.  They have also stated that ASA for heart disease, BRCA testing and nicotine patches are preventative and can not be patient charged.  This will raise premiums for both group and individual insurance coverages.  Conception prevention is also preventative including both long term implant or or intrauterine devices.  These can be done by out of network physicians if the network has no one to do it.  

The administration has also finalized mental health rules.  Sebelius has said that substance abuse, both alcohol and drug, and mental health coverage are part of all insurance policies under the regime. This will give this coverage to 62 million people who do not have the coverage now.  This is good but the costs will be tremendous, well over $100 million.  There will also be four type of plans ranging from the patient paying 40% of the costs of covered benefits to them paying 10% of the costs.  The plans will be guidelines and states may set their own requirements.  The states will have to offer the benefits covered prior to December 31, 2011.  Anything above that the state will have to pay.  Therefore, the uniformity that Sebilius is stating will not be.  

The feds have been embarrassed enough.  They have cancelled the ill-fated Pre-Existing Condition Health Plan.  Since its inception only 135,000 people nationwide have enrolled due to the high premium costs involved.  This is 1/3 of the expected enrollment.

The Swiss have cut the blood they send to Greece to help with their Thalassemia problem.  The reason is two fold: the first and foremost is that Greece pays their bill chronically late and the Swiss want to limit their potential losses.  The second is to encourage Greece to build up their own blood banks.        Top


We are now into March and the feds have not yet paid any money to the states so the states can pay the Medicaid primary providers the promised increased pay to Medicare rates.  The feds blame it on the states for not submitted the required forms.  

The sequester will be good for providers.  They get less taken away under this (2%) than if deficits were actually reduced.  The deficit reduction would take away $500 Billion whereas the sequester will take away $100 Billion over a decade.  Hospitals get hit for about 40% of the loss followed by Medicare Advantage and then physicians under the sequestration.        Top



DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.