The Trump Administration (following MedPAC recs) laid out a path forward to pay the same price for physician services that can be performed safely in the office setting even if they take place in a hospital outpatient department or hospital-owned physician’s office.
Despite an ability to cover the base Medicare benefit for less $ than traditional Medicare in general, taxpayers still pay more $, on avg, when an enrollee chooses MA. And this subsidy to MA enrollees varies unevenly across the country.
@MattAFiedler shows we can shave off ~41% of the cost of the new dental/vision/hearing benefit by not passing through those costs to MA benchmarks w/ minimal impact even on MA enrollees’ supplemental benefits:
There are also further options to save $$ by reducing MA plan’s coding intensity advantages over traditional Medicare and/or changing the benchmark formula.
Lastly, a mainstay of basically every Obama and Trump budget, plus a consistent MedPAC recommendation, there’s a fair amount of savings available from reducing what are arguably excessive payments to post-acute care providers in Medicare.
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Given the "why not both" option if the US were willing to pay high prices for doses then donated to other countries & US-first focus of US policy, I'm skeptical the practical effect on doses donated to other countries is large.
But curious how others think about this ...
The other key parameter here is that we're almost certainly going to need boosters at some point in the not-too-distant future, thus further minimizing any potential trade-off.
Moreover, arbitration awards >25x median in-network prices were not uncommon.
New Jersey, similar to New York, illustrates the danger of basing an arbitration system on unilaterally-set provider charges.
Such an approach is destined to unnecessarily increase health costs.
However, it's important to disentangle the benchmark from the mechanism. Arbitration in it of itself is not necessarily the problem in New Jersey (or NY). The problem is basing decisions on the 80th %-tile of provider charges, an extremely high amount untethered by mrkt forces.
Today’s surprise billing fix is a huge win for consumers!
As of 1/1/2022, it will be illegal nationwide for an out-of-network provider to surprise bill a patient for more than their standard in-network cost-sharing obligations.
The protections from surprise billing will apply in all emergency situations (w/ lone exception of ground ambulance rides) & for non-emergency out-of-network physician services received at in-network facilities.
These are arguably broader than the protections in any state law and will be difficult to game.
Patients can now feel safe they won't get a surprise bill from the emergency room or from an anesthesiologist or assistant surgeon involved in their elective surgery.
27 Senators sign a bipartisan letter supporting inclusion of the recently-announced surprise billing agreement in the year-end spending legislation: cassidy.senate.gov/imo/media/doc/…
Unfortunately, the AMA is opposing the bipartisan surprise billing legislation.
Interestingly, they previously seemed to support the Neal/Brady bill (left), and the new bill is identical other than a couple concessions to provider lobbying.
The way this is written, you’d think AMA and other provider groups weren’t the ones pushing arbitration (and the administrative headache that goes along with it) this whole time.
Surprise billing would be prohibited for all OON emergency services (& post-stabilization), much OON care at in-network facilities, & air ambulances.
Out-of-network payment can be challenged to an arbitration process that's instructed to mainly consider median in-network rates.
Arbitration can be a bit clunky & opaque (& adds administrative cases), but the legislation does a pretty good job placing guardrails on the process to prevent abuses.
1) There's a strong anchor to median contracted rates
While the debate has largely broken down as benchmark vs. arbitration, much more important is how generous the out-of-network payment mandate ends up being.
E.g., arbitration based on Medicare rates would be more consumer-friendly than a benchmark based on charges.
Or to take concrete state examples, CT's surprise billing law that uses an OON benchmark payment mandate at the 80th percentile of charges for emergency services is just as bad for consumers as NY's that relies on arbitration to get to the same end state.
Or in a more consumer-friendly fashion, NH's law that strongly anchors their arbitration process to median in-network rates ends up pretty similar to CA or OR laws that get to a similar place through a benchmark.