As of Tuesday evening, Dec. 20, a 4,155-page, $1.7-trillion omnibus spending bill was wending its way through Congress, with bipartisan support; and though nothing is certain in the congressional legislative process until legislation is completed, the bill appeared to be headed towards passage in both the U.S. House of Representatives and the Senate by Friday. Leaders of associations representing every type of healthcare provider organization and payer organization responded with praise or alarm depending on the specific elements of the legislation in question, and on their positions on a variety of current federal healthcare policy and reimbursement issues.
A report from the American Hospital Association (AHA) posted to the association’s website at 3:03 PM eastern time on Tuesday stated the following:
“The legislation would:
- Prevent the 4-percent Statutory Pay-As-You-Go (PAYGO) sequester for two years;
- Extend for two years critical rural Medicare programs, telehealth flexibilities and the Acute Hospital Care at Home;
- Reduce the physician fee schedule cut from 4.5 percent to 2% for 2023 and approximately 3% for 2024;
- Provide 200 additional Medicare-funded graduate medical education positions, half of which would be dedicated to psychiatry and psychiatry subspecialty residencies;
- Take several steps to improve access to behavioral health services;
- Make improvements to the government’s ability to prepare for future emergencies.”
Per those provisions, AHA president and CEO Rick Pollack released a statement in which he said that “The AHA is pleased that on a bipartisan basis Congress recognizes the immense pressure America’s hospitals, health systems and our caregivers are facing. This legislation will deliver critical support and resources so we can better care for our patients and create healthier communities. Due to skyrocketing cost increases for supplies, equipment, drugs and labor, challenging workforce shortages, and the ‘tripledemic’ of COVID-19, flu, and RSV, the hospital field is stretched thin and on the brink.”
Pollack went on in the statement to say that, “Specifically, we are pleased that this bill prevents significant four percent Medicare PAYGO cuts to providers, extends two key programs for two years that help rural hospitals keep their doors open, and extends for two years critical waivers for telehealth and hospital-at-home programs that have led to improvements in care and made medical treatment more convenient and accessible for patients. Additionally, we appreciate Congress giving partial relief to physicians by rolling back Medicare payment cuts and including important provisions to improve the nation’s preparedness for the next pandemic, train the next generation of caregivers, bolster behavioral health care providers and expand access to behavioral health services. Finally, helping states prepare for changes in Medicaid eligibility due to the end of the Public Health Emergency could help them transition those individuals to other forms of health coverage. However,” he added, “this is just a part of what needs to be done to support those on the front lines caring for patients. In the new year, we will continue to advocate for Congress and the Administration to take action to address patient discharge backlogs, support our current workforce and increase the pipeline into the future, hold commercial health insurers accountable for policies that compromise patient safety and add burden to care providers, and strengthen hospitals that care for a disproportionate number of patients covered by government programs or are uninsured, to name a few of our priorities.”
The initial version of the legislation had instituted a 4.5-percent physician reimbursement cut under Medicare, but the version moving through Congress on Thursday had reduced that cut to 2 percent. Even so, the American Medical Association (AMA) released a statement denouncing that planned cut. In a statement attributed to Jack Resneck Jr., M.D., the AMA’s president, read thus: “The AMA is extremely disappointed and dismayed that Congress failed to prevent Medicare cuts next year, threatening the financial viability of physician practices and endangering access to care for Medicare beneficiaries. This 2% cut following two decades of flat payment rates will have consequences on health care access for older Americans. High inflation compounds the threat to practice viability because physicians are the only Medicare providers without annual inflation-based updates. We are deeply worried that many practices will be forced to stop taking new Medicare patients – at a time when access to care is already inadequate. Congress must immediately begin the work of long-overdue Medicare physician payment reform that will lead to the program stability that beneficiaries and physicians need.”
The Medical Group Management Association (MGMA) was also alarmed by the 2-percent Medicare payment cuts to physicians. “On behalf of our nation’s medical groups — ranging from small physician practices in rural areas to large regional and national health systems — MGMA is deeply dismayed by the failure of Congress to adequately address the full 4.5-percent cut to the Medicare conversion factor set to take effect on Jan. 1,” Anders Gilberg, senior vice president, government affairs, at MGMA, said in a statement posted to the association’s website on Thursday afternoon. “It is unconscionable that while every other provider category in the Medicare program is receiving a positive 2023 inflation update, physician rates will be cut. Medical practices are in no way immune to the impact of the broader economy, and have been suffering from significant staffing shortages, wage inflation, and drastic cost increases across the board. Any cut to the Medicare conversion factor is simply untenable in this environment.”
What’s more, Gilberg added in his statement, “This short-sighted cut will exacerbate growing access to care issues faced by Medicare beneficiaries across the country. In fact, 92 percent of medical groups reported that Medicare reimbursement in 2022 already fails to adequately cover the cost of care provided — and that’s before the additional cut is scheduled to take effect on Jan. 1. Should Congress fail to avert the full 4.5% cut in final legislation this week, medical groups have reported they will be forced to make tough business decisions such as limiting the number of Medicare patients served, laying off clinical staff, and closing satellite locations.”
Leaders at the American Society for Radiation Oncology (ASTRO) were also dismayed. A statement attributed to the chair of ASTRO’s board of directors Geraldine Jacobson, M.D., M.P.H., read as follows: "On behalf of ASTRO’s 10,000 members who are physicians, nurses, biologists, physicists, radiation therapists, dosimetrists and other health care professionals who specialize in treating cancer patients with radiation therapy, ASTRO is disappointed that Congress failed to stop the full Medicare physician payment cuts for 2023, demonstrating that the Medicare physician payment system is broken. Radiation oncology has faced among the most significant cuts of any medical specialty, leaving community-based clinics at the breaking point. We urge the new Congress to immediately begin payment reform discussions, including working with ASTRO and the radiation oncology community to create a new, sustainable payment approach for radiation therapy services.”
Further, Dr. Jacobson stated, “The omnibus package leaves all physicians with a 2-percent reduction in the Medicare physician payment conversion factor for 2023, and radiation oncology with an additional 1-percent decrease due to clinical labor price changes, at a time when patients are returning to clinics and facing more complex cancer care due to delays caused by the pandemic. Cancer clinics must also contend with a wide range of increasing overhead and staffing costs when determining their ability to provide care to Medicare beneficiaries. Payment relief in the omnibus bill is insufficient and could endanger some clinics’ ability to stay open and provide needed care to people with cancer.”
Medicaid factors
Meanwhile, Nathaniel Weixel and Joseph Choi of The Hill reported on Thursday evening that “States will be allowed to begin kicking people off their pandemic-enhanced Medicaid coverage in April as the federal government phases out the extra funding states have received since the earliest days of the pandemic. Removing Medicaid coverage from the public health emergency was a major priority for Republicans, but it would also give state health officials certainty. The public health emergency did not have a firm end date,” they wrote, “so state Medicaid officials never knew when they would have to start going through their Medicaid rolls to figure out who was no longer eligible.”
That said, a national coalition of seven consumer health and safety net organizations issued a statement praising the Medicaid provisions of the legislation. The statement noted that “The bill includes provisions that strengthen health coverage for people with low incomes by ensuring 12 months of continuous eligibility for children covered under Medicaid and CHIP, a permanent extension of the state option to provide 12 months of postpartum coverage for those enrolled in Medicaid and CHIP, a 2-year extension of funding for CHIP, and providing Medicaid and CHIP coverage of screening, diagnostic, referral, and care coordination services to incarcerated juveniles 30 days prior to their release.” Per that, the coalition stated, “Medicaid and CHIP are lifelines for tens of millions of Americans. The inclusion of these Medicaid and CHIP policies gives us hope that Congress is serious about ensuring access to quality health coverage. Collectively, these policies have the potential to add stability to a frequently fragmented healthcare system and, more importantly, to improve the health and well-being of people with low-to-middle incomes. These policies are an excellent step forward in the right direction and will meaningfully improve the health and well-being of many people. Yet, we know there is more work to be done. In particular, we were hoping to see a provision in the bill that would provide incarcerated adults Medicaid coverage 30 days prior to their release. A policy as such is critical to support this population, which has significant health care needs, including mental health and substance use disorders. Only with continued action can we assure that all individuals have equitable access to quality health care. The Coalition looks forward to working with Congress in the future on such efforts and will continue our mission of advocating to strengthen Medicaid and CHIP for the benefit of all Americans.
The National Medicaid Coalition “is a national partnership of seven organizations in the health and safety net sector - the American Academy of Pediatrics, the Association for Community Affiliated Plans, Children’s Hospital Association, Community Catalyst, Families USA, First Focus Campaign for Children, and the National Alliance on Mental Illness, each of which has decades of experience advocating for equitable access to quality health care.”
NAACOS pleased by inclusion of value-bed care incentive
What about value-based contracting under Medicare and the development of accountable care organizations (ACOs)? Leaders at NAACOS, the National Association of ACOs, offered praise for one measure in the omnibus bill. "We greatly appreciate Congress including a 3.5 percent value-based care incentive in a year-end spending bill. NAACOS and others have been calling on lawmakers to extend these critical incentives so that our health system can maintain momentum on its value-based care movement,” said Clif Gaus, Sc.D., NAACOS’s president and CEO. “Care for millions of patients will be better off because the health system is rewarding doctors for providing higher quality care at lower cost. While this is not the full 5 percent that providers have been receiving and NAACOS asked for, it does maintain some incentive to keep the momentum while Congress works on a long-term solution to encouraging adoption of alternative payment models,” Gaus continued. “This should be considered a bridge toward greater reforms needed to encourage providers’ move into accountable care organizations. Without additional carrots and sticks, doctors and hospitals will continue to be stuck in a volume-driven, fee-for-service payment system that discourages keeping patients healthy and out of the hospital. Instead, we need more patients and providers in value-based models, and the next Congress will play a critical role in work to overhaul our physician payment system."
The bill also includes a two-year extension of telehealth flexibilities, with the waivers authorizing those flexibilities because of the COVID-19 pandemic extended through Dec. 31, 2024. The flexibilities include eliminating geographic restrictions on originating sites for telehealth services, enabling Medicare beneficiaries to receive services from any location, and allowing federally qualified health centers and rural health centers to continue providing telehealth services.
“The legislation includes provisions to extend and expand telehealth flexibilities through Dec. 31, 2024. Under current law, many of these flexibilities were set to expire 151 days after the end of the COVID-19 PHE. These include:
- Expanding originating site to include any site at which the patient is located, including the patient’s home;
- Expanding eligible practitioners to furnish telehealth services to include occupational therapist, physical therapist, speech-language pathologist and audiologist;
- Extending the ability for federally qualified health centers (FQHCs) and rural health clinics (RHCs) to furnish telehealth services;
- Delaying the six-month in-person requirement for mental health services furnished through telehealth, including the in-person requirements for FQHCs and RHCs;
- Extending coverage and payment for audio-only telehealth services; and
- Extending the ability to use telehealth services to meet the face-to-face recertification requirement for hospice care.
In addition, the Department of Health and Human Services (HHS) Secretary would be required to submit a report to Congress on utilization of services (interim report in October 2024; final report in April 2026). Additionally, the omnibus bill would extend safe harbor exceptions for telehealth services in high-deductible health plans.
"Today, our Congressional telehealth champions on both sides of the aisle came through for the American people and for ATA and ATA Action members, by meeting our plea for more certainty around telehealth access for the next two years, while we continue to work with policymakers to make telehealth access a permanent part of our healthcare delivery for the future," said Kyle Zebley, senior vice president of public policy at American Telemedicine Association and executive director of the association's advocacy arm, ATA Action, in an emailed press release.
In addition, per hospital-at-home programs, the AHA noted that “The legislation would extend the Acute Hospital Care at Home initiative until Dec. 31, 2024. The bill also would require the HHS Secretary to analyze and compare care delivery under Acute Hospital Care at Home programs with traditional inpatient care delivery and publish a report demonstrating those findings.”
This is a developing story. Healthcare Innovation will update this story as new developments warrant.
