RISE summarizes recent headlines that impact the health care industry.

UHC urged to abandon ‘dangerous’ ER policy

The American College of Emergency Physicians (ACEP) and 32 organizations made up of patient advocates, hospitals, and physicians across medical specialties this week called on UnitedHealthcare (UHC) to permanently abandon its planned policy to retroactively deny patients’ emergency care claims. These denials violate federal law and put lives at risk, health care leaders said in a letter sent to UHC this week. The letter is in response to the insurer’s plan to reject claims for non-emergency visits to the emergency room.

UHC originally intended to implement the policy on July 1, but after intense backlash following the announcement, the company delayed the rollout until the end of the pandemic. The policy is meant to discourage unnecessary use of the emergency room, but the ACEP said it is based on the faulty assertion that patients should know what symptoms constitute a medical emergency.

The letter argues that the policy is especially dangerous for vulnerable patients—many of whom rely on the emergency department as their primary or only source of care.

Instead of delaying the policy, the ACEP called on UHC to abandon it. Millions of patients may delay or avoid seeking emergency care because they worry their insurer will leave them with the bill, the ACEP said.

“It will have a chilling effect on patients’ decisions to seek care, whether for themselves or for a loved one…Such hesitation could be life-threatening or result in even greater costs to the healthcare system down the road.”

“Only full and permanent rescission of the policy will ensure the safety of our patients and your enrollees, and we urge you to take such action immediately,” the letter concludes.

MedPAC suggests Congress recalculate MA benchmarks, payments

In its June report to Congress, the Medicare Payment Advisory Commission (MedPAC) called for changes to the way payment benchmarks are determined for the Medicare Advantage (MA) program. MedPAC estimates that Medicare currently spends 4 percent more per capita for beneficiaries enrolled in MA than it spends for similar enrollees in traditional fee-for-service (FFS) Medicare.

The existing policy uses a quartile system that generates geographic variation in plan payments, including plan subsidies of varying size in most geographic areas, that are not necessary for maintaining affordable supplemental coverage and that fail to capture savings for the Medicare program. MedPAC said that the quartile-based benchmarks support higher payments to MA plans in areas where FFS spending is low. Despite most plans bidding below FFS spending in these areas, payments are 9 percent higher than the areas’ FFS spending, and MA enrollment is disproportionately higher than in many other areas. A better policy, according to the commission, would rebalance benchmarks to allow the Medicare program to capture some MA efficiencies while mitigating potential decreases in plan participation and benefits.

MedPAC recommends that Congress implement a new MA benchmark policy that:

  • Uses a relatively equal blend of per capita local area FFS spending and standardized national FFS spending. This would allow benchmarks in low-FFS-spending areas to better align with local FFS spending. On average, benchmarks in areas with high FFS spending would modestly decrease relative to current policy, allowing the program to capture additional efficiencies in areas where plan bids are lowest relative to their benchmarks.
  • Uses a rebate of at least 75 percent. The rebate percentage (i.e., the share of the difference between the plan bid and benchmark) that is paid to plans for funding extra benefits would be decoupled from the MA quality bonus program and would increase for all plans to create greater incentives for plan efficiency.
  • Integrates a discount rate of at least 2 percent. A discount rate would reduce the local-national blended spending amounts, integrating the efficiency of MA into the benchmark calculation. A discount rate of at least 2 percent would help ensure that the Medicare program shares in the efficiencies generated by MA.

CMS increases payment for in-home COVID-19 vaccinations to Medicare beneficiaries

The Centers for Medicare & Medicaid Services (CMS) has announced it will provide additional payment for administering in-home COVID-19 vaccinations to Medicare beneficiaries who have difficulty leaving their homes. There are roughly 1.6 million adults who are 65 or older who may have trouble accessing vaccinations because they are home-bound. Medicare will pay providers an additional $35 per dose for the vaccine administration in a beneficiary’s home, increasing the total payment amount to $75 per vaccine dose. For a two-dose vaccine, this will result in a total payment of $150 for the administration of both doses or approximately $70 more than the current rate. Providers may not bill patients for the vaccines but can seek reimbursement through Medicare, Medicaid, private insurance, or other applicable coverage. Most group health plans and health insurers are statutorily required to cover COVID-19 vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention without cost-sharing.