MSSNY eNews: October 8, 2021 – “No Surprises Act” Puts Insurance Co Profits Over Patient Care
“No Surprises Act” Puts Insurance Co Profits Over Patient Care
As physicians, our first and foremost concern is the health and well-being of our patients. But when insurance company profits take precedence over patient care, it makes that mission—our life’s work—more difficult. And that’s exactly what is happening with the recently announced US Department of Health and Human Services (HHS) regulations to implement the “No Surprises Act.”
The Congressional intent in the “No Surprises Act” was to create a federal independent resolution (IDR) process to protect patients that was appropriately balanced and did not favor either the insurer or the physician in claims disputes. The final language adopted by Congress required the arbiter to consider numerous factors, including patient acuity or complexity of services, demonstrations of previous good faith efforts to negotiate in-network rates and previously contracted rates, and the insurers’ median in-network rate—without specifying that one factor take precedence over another.
Instead of following the statutory language, HHS and other federal agencies designed an IDR process that heavily favors health insurance companies in payment disputes. The language in the rule directs the IDR arbiter to give priority to the insurer-calculated median in-network amount—called the qualifying payment amount (QPA)—over the other considerations noted above. It also imposes a number of requirements on the arbiter if they decide to make a decision that deviates from the insurer-determined QPA. This effectively ties the hands of the arbiter.
As I said in a press statement when the regulations were announced last week, “In implementing the IDR process for resolving patient surprise medical bills – a process that New York physicians have strongly supported for many years – HHS has clearly sought to put its thumb on the scale in favor of multi-billion-dollar insurance companies.”
Indeed, we have had a well-functioning and balanced IDR process in New York for several years for claims under state-regulated plans. What passed Congress last year was supposed to emulate New York’s approach. But HHS has unfortunately taken a completely wrong turn. Therefore, MSSNY will work with the AMA and other allied groups to advocate for needed changes to the regulation to ensure that the IDR process is implemented in a way that better achieves balance in the IDR process.
But we need you—the physicians who care for patients every day—to make it clear to HHS that the health of Americans is more important than insurance company profits. Let’s all speak up and make our voices heard—for the sake of our patients. I encourage you to contact Senators Schumer and Gillibrand and your Congressional Representative to urge them to request that HHS revise their regulations and establish a federal IDR for out of network surprise bills.
HHS needs to take their thumb off the scale in favor of insurance companies—and instead prioritize the health of all Americans.
NY Congressional Delegation Urges Action Before End of 2021 to Prevent Devastating Cuts to Medicare Payments to Physicians
With physicians facing a nearly 10% cut in payments from Medicare starting January 1, 2022, 13 members of the New York Congressional Delegation added their name to a letter by Representative Ami Bera, MD (D- CA) and Representative Larry Bucshon (R- Indiana), to House leaders Representatives Nancy Pelosi (D- CA) and Kevin McCarthy (R- CA), urging them to act before the end of the year to prevent devastating cuts to physicians’ Medicare payments. Nearly 200 Congressional members in total have joined the letter.
The current Medicare payment system does not adequately incentivize high-quality care and payments to physicians has failed to keep up with inflation. Broad systemic reforms to the Medicare payment system are needed to address the growing financial uncertainty and to speed the transition to value-based care. The letter urged Congress to create stability by addressing the immediate payment cuts facing health care professionals as it begins the complex process of identifying and considering potential long-term reforms, pointing out that cuts will strain the health care system and jeopardize patient access to medically necessary services.
Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA) with the goal of moving away from a fee-for-service payment model to a system that ensures providers are paid for the work they do to keep patients healthy, not just treat them when they’re sick, but most practices lack access to qualified, patient-centered alternative payment models under MACRA. Additionally, the Medicare Physician Fee Schedule (PFS) has failed to keep up with inflation and larger increases to some providers must be offset by cuts to other providers, even if there’s no evidence of overpayment, due to a budget neutrality provision in statute, that further contributes to the financial pressure on health care professionals. Health care professionals are also facing imminent payment cuts stemming from the Medicare sequester and the Statutory Pay-As-You-Go (PAYGO) Act.
The letter also recognized action taken in the Consolidated Appropriations Act, 2021 to mitigate the impact of payment cuts initiated by the CY 2021 PFS. The Consolidated Appropriations Act contained a 3.75 percent payment adjustment for all PFS services in CY 2021 as part of congressional relief provided for the impending payment cuts. This payment adjustment afforded some short-term stability for health care professionals struggling with the impact of the COVID-19 pandemic. However, this critical piece of congressional relief is expiring at the end of the calendar year and adds to other impending cuts.
We thank the following NY Delegation members who signed on to the Bera-Buschon letter:
1. Representative Yvette Clarke (D- Brooklyn)
2. Representative Antonio Delgado (D- Hudson Valley)
3. Representative Andrew Garbarino (R- Long Island)
4. Representative Brian Higgins (D- Buffalo)
5. Representative Chris Jacobs (R- Western New York)
6. Representative John Katko (R- Central New York)
7. Representative Carolyn Maloney (D- Manhattan)
8. Representative Grace Meng (D- Queens)
9. Representative Joe Morelle (D- Rochester)
10. Representative Nicole Malliotakis (R- Staten Island)
11. Representative Kathleen Rice (D- Long Island)
12. Representative Tom Suozzi (D- Long Island)
13. Representative Paul Tonko (D- Capital District)
Need Assistance with Insurance Issues? Make Sure Your MSSNY Membership is Current!
MSSNY regularly receives requests from physicians to intervene on their behalf with insurance company or state enforcement agencies. Remarkably, some physicians reach out for assistance without having paid their membership dues. Please understand this is a member only benefit. We help countless physicians every day to resolve issues. Make sure your MSSNY membership is up to date so that when you need assistance with an insurance company or state enforcement agency matter, we can help you! Join MSSNY today!
MSSNY Continues to Raise Concerns to State Government Officials with Unnecessary Scope Law Waivers
MSSNY physician leaders have met and continue to communicate with top officials to Governor Kathy Hochul this week to praise her efforts to require all healthcare workers to be vaccinated against Covid, but at the same time raise concerns with aspects of her September 28 Executive Order No. 4: Declaring a Statewide Disaster Emergency Due to Healthcare Staffing Shortages in the State of New York (ny.gov) which appear to go beyond addressing the immediate staffing crisis at hand in hospitals arising from enforcement of the September 27 vaccination mandate.
In a meeting last week, MSSNY physician leaders praised Governor Hochul for sticking to the requirement that had been adopted by the Department of Health in August. In particular, MSSNY noted that the enforcement of the requirement was an essential step resulting in the significant increase in the health care worker vaccination rate across New York State.
To respond to the overall reduced supply of some healthcare workers and to ensure the proper functioning of hospitals and other health care facilities, Governor Hochul’s Executive Order waived for 30 days various licensure and scope of practice requirements under the public health law, insurance and education law such as permitting out of state health care workers including physicians, RNs, LPNs, NPs, PAs, midwives, clinical nurse specialists, licensed master social workers, and licensed clinical social workers to practice in New York to replace those healthcare workers who have not been vaccinated or received an exemption.
Some of the aspects of the Executive Order are items for which MSSNY is supportive, including measures that would permit physician visits in nursing homes to be done using telemedicine, and suspending requirements for preauthorization review by health insurers for scheduled surgeries in hospital facilities, hospital admissions, hospital outpatient services, home health care services following a hospital admission.
However, very concerning are provisions in the Executive Order that waive existing laws which require supervision of CRNAs by anesthesiologists, require supervision of health care service delivered by physician assistants by physicians, and require collaborative arrangements between nurse practitioners and physicians. MSSNY President Dr. Joseph Sellers, MSSNY President-elect Dr. Parag Mehta and MSSNY Past-President Dr. Bonnie Litvack noted that these measures are not necessary to respond to the shortage of healthcare workers because very few physicians working in hospitals and healthcare facilities have not been vaccinated, and that the waiving of these laws places patients at unnecessary risk.
Both the MSSNY physician leaders and Governor Hochul’s staff expressed hope that the Executive Order provisions would only be temporary – it is due to expire October 27 – because most of the remaining healthcare workers without proper exemptions would get vaccinated.
New Report Shows Rapid Uptick in Physicians’ Use of Telehealth
A new report based on the AMA’s Physician Practice Benchmark Survey describes the rapid uptick in physicians’ use of telehealth between Sept. 2018 and Sept. 2020. Over that period, the share of physicians in practices that used videoconferencing to provide patient visits increased from 14.3% to 70.3%. The report also shows that telehealth was used to treat a diverse set of patients with a variety of needs. In 2020, 58.0% of physicians said their practices used telehealth to diagnose or treat patients, 59.2% to manage patients with chronic disease and 50.4% to provide care to patients with acute disease.
Registration Now Open
October 20, 2021 @ 7:30am Medical Matters CME Webinar
Influenza: In the Time of Pandemic 2021-2022
The 2020-2021 flu season was negligible owing to a variety of reasons. Now that restrictions are lifting, the 2021-2022 flu season will once again be a matter of concern. Learn more by registering for “Influenza: In the Time of Pandemic 2021-2022” on Wednesday October 20, 2021 at 7:30 a.m. William Valenti, MD, chair of MSSNY Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee will serve as faculty for this program. Registration is now open for this webinar here. Click here to view the flyer for this program.
Educational objectives are:
- Examine the dramatic decrease in influenza cases in 2020-2021
- Identify strategies to effectively encourage patients to get vaccinated
- Analyze measures to ensure continued abatement of influenza during and after the COVID pandemic
- Discuss timing of influenza vaccines with COVID-19 vaccination
Additional information or assistance with registration may be obtained by contacting Melissa Hoffman at email@example.com.
The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Competition in Health Insurance: A Comprehensive Study of U.S. Markets
The AMA recently released its 2021 Update to Competition in Health Insurance: A Comprehensive Study of U.S. Markets (PDF). This study reports the two largest health insurers’ market shares and market concentration (HHI) levels in each of the 384 metropolitan statistical areas (MSAs), the 50 states and the District of Columbia.
For the first time, the report also presents national-level market shares for the 10 largest health insurers in the U.S. The study finds that the average HHI increased by 171 points to 3494 between 2014 and 2020, while the share of markets that are highly concentrated rose from 71% to 73%. 57% of markets experienced an increase in the market concentration level (HHI). Among those markets, the average increase was 531 points. 54% of markets that were already highly concentrated in 2014 became even more concentrated by 2020.
The study also finds that a Blue Cross Blue Shield affiliate had the largest market share in 81% (311) of MSAs. Finally, UnitedHealth Group was the largest commercial health insurer at the national level, while Centene was the largest insurer in the exchanges. Learn more.
Frequency of Anxiety, Depression Symptoms Among U.S. Adults Amplified During Winter COVID-19 Surge, Research Suggests
CDC’s Morbidity and Mortality Weekly Report finds that nationwide, average anxiety severity scores increased 13% from August to December 2020 and then decreased 26.8% from December 2020 to June 2021. Similar increases and decreases occurred in depression severity scores. The Hill (10/5, Coleman) reports, “The frequency of anxiety and depression symptoms among American adults amplified during the winter COVID-19 surge, according to a” CDC “study showing the pandemic’s impacts on the country’s mental health.”
The study, “spanning from August 2020 to June 2021, found anxiety and depression frequency peaked between December 2020 and January 2021, as COVID-19 cases skyrocketed to new heights during the holiday season.” Despite a drop of 26.8% by June 2021, researchers also found that “the frequency of anxiety and depression still remained ‘substantially’ higher than compared to before the pandemic.”
CASSELL, Eric Jonathan; New York NY. Died September 24, 2021, age 93. New York County Medical Society Inc.
DI BENEDETTO, Guido J.; Staten Island NY. Died February 21, 2020, age 86. Richmond County Medical Society Inc.
KESSLER, Richard A.; East Amherst NY. Died July 18, 2021, age 71. Erie County Medical Society”
ORPHANOS, Richard P.; New York NY. Died August 14, 2021, age 90. New York County Medical Society Inc.
ROBERTS, Thomas Nelson; New York NY. Died August 15, 2021, age 96. New York County Medical Society Inc.
SCHWARTZ, Stuart Jay; West Palm Beach FL. Died September 14, 2021, age 85. Medical Society County of Oneida Inc.
VERCILLO, Arthur Angelo; Liverpool NY. Died August 19, 2021, age 97. Onondaga County Medical Society Inc.
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Health Research, Inc. (HRI) has a job opening within the AIDS Institute’s Office of the Medical Director for a Public Health Physician II. Please distribute this announcement widely through your networks. Interested individuals can apply for this position through the HRI website.