RISE summarizes recent regulatory news.

HHS likely to renew COVID-19 PHE in January

Reuters reports that the U.S. Department of Health and Human Services (HHS) will renew the public health emergency (PHE) status of the COVID-19 pandemic in January.

HHS Secretary Xavier Becerra had promised to give states 60 days’ notice in the event it would let the emergency expire. That date would have been on Friday, Nov. 11 and no notice was given, according to White House officials who spoke to the media outlet. Fears of a surge in infection this winter is one reason the federal government wants to keep the PHE in place, they told Reuters.

The emergency declaration allows providers and health plans to better respond to COVID-19 by taking advantage of flexibilities, including the waiving of telehealth restrictions and cost-sharing for COVID-19 tests. Former HHS Secretary Alex Azar first declared the coronavirus as a PHE in January 2020. It has been renewed 11 times since the beginning of the pandemic. The current declaration, signed October 13, will expire on January 11, 2023.

Alternative payment model survey shows progress on two-sided risk

An annual alternative payment model survey, conducted with the support of AHIP and the Blue Cross Blue Shield Association, looks at how widely value-based care models are being adopted by health insurance providers and health care systems. The Health Care Payment Learning & Action Network (LAN) survey for calendar year 2021 finds:

  • Participation in risk-based models increased with 20 percent of U.S. health care payments flowing through risk-based advanced payment models.
  • Medicare Advantage plans lead the way, with 57 percent of payments flowing through any sort of advanced payment model and 35 percent of payments flowing through risk-based advanced payment models.
  • Many plans leverage value-based care arrangements to improve health equity. For example, 46 percent provide incentives to providers to collect standardized race, ethnicity, and language data. Thirty-seven percent provide incentives for screening for socioeconomic barriers through these arrangements.
  • Eighty-three percent of payers believe that engagement in advanced payment models will increase in the future.

“There is no question that many strains were placed on America’s health care system in 2021, as everyone worked together to overcome the COVID-19 pandemic. Yet, value-based payment models were a constant, with increasing participation in arrangements that enable providers to share both the risk and rewards,” said AHIP President and CEO Matt Eyles in an announcement about the survey findings. “These findings support what we have heard from our members, particularly over the last three years: Value-based payment models are not only good for patients, they are good for clinicians, hospitals and health care systems by supporting these partners through greater financial predictability, stability and flexibility even in the most dire health crises.”

KHN investigates private equity’s stealth takeover of U.S. health care

A new investigation by Kaiser Health News finds that private equity firms have invested nearly $1 trillion through thousands of deals to acquire hospitals and specialized medical practices during the last decade alone.

The deals, many of them unnoticed by federal regulators, typically result in a ratcheting up of providers’ pursuit of profit –and higher prices for patients, lawsuits, and complaints about quality of care, the Kaiser Family Foundation said in an announcement about the report.

The investments range widely and include the acquisitions of physician practices, dental clinic management companies, companies that treat autism, drug addiction and other behavioral health care, and ancillary services such as diagnostic and urine testing labs and software for medical billing. Through other deals, companies tied to private equity have come to dominate specialized medical services such as dermatology, gastroenterology, and anesthesiology in certain markets around the country. All of it has come on top of better-publicized takeovers of hospital emergency room staffing firms as well as the buying up of entire rural hospital systems.

Federal regulators have been almost blind to the incursion, according to the report. KHN found that more than 90 percent of private equity takeovers or investments fell below the $100 million threshold that triggers an antitrust review by the Federal Trade Commission and the Justice Department.

Whistleblowers and injured patients, however, have turned to the courts to press allegations of misconduct or other improper business dealings. KHN found that companies owned or managed by private equity have agreed to pay fines of more than $500 million since 2014 to settle at least 34 lawsuits filed under the False Claims Act. Most of the time, private equity owners have avoided liability.

AMA calls for federally maintained physician directory

The American Medical Association’s House of Delegates voted this week to urge the federal government to create and maintain a public database of physicians who participate in MA and are accepting new patients. The AMA policy addresses the expectation that MA plans present an accurate list of in-network physicians to help patients make informed choices and find suitable medical care.

“Patients rely on directories of in-network physicians to make informed comparisons of Medicare plans or choose a physician,” AMA Board Member Scott Ferguson, M.D., said in a statement.  “But patients face a false appearance of choice when Medicare Advantage plans create networks that are too thin and directories that are too flawed. A comprehensive and authoritative source of accurate information is needed from federal authorities to support patients in Medicare Advantage.”

The new policy also instructs the AMA to advocate for better enforcement of MA regulations and work for greater accountability from the Centers for Medicare & Medicaid Services to ensure patients have transparent information access to understand which medical services are covered by their MA plans and which ones are not.