Lown Finds Overuse Of Unnecessary Back Surgeries
The respected Lown Institute, a healthcare researcher and policy group, has found that hospitals performed over 200,000 unnecessary back surgeries on older adults over a three-year period in Medicare. The hospitals billed a total of more than $1.9 billion for what Lown says are low-value services.
Lown also found that 60% of total overuse for spinal fusion/laminectomies came from the 10% of worst offender physicians. It notes that these unnecessary procedures cause a rise in serious complications. One example: spinal fusion complications occur in up to 18% of patients and can lead to stroke, pneumonia, or death.
Lown looked at Medicare fee-for-service (FFS) claims from 2021 to 2023 and Medicare Advantage (MA) claims from 2020 to 2022 for rates of spinal fusions/laminectomies and vertebroplasties that met the researchers’ criteria of a low-value procedure based on the patient’s clinical presentation at the time of admission.
There were disparities by facility in terms of the overuse. The Cleveland Clinic and the University of Michigan Health System had vertebroplasty overuse rates below 1%, while AdventHealth Orlando and Mayo Clinic Hospital Phoenix had 23% and 17% overuse. The same Mayo Clinic location scored well on spinal fusion/laminectomy overuse with a 6.3% rate, while the Hospital of the University of Pennsylvania had a 33.3% overuse rate and Stanford Hospital had one of 22.7%.
Interestingly, the procedures are among 17 services targeted in a new proposed Center for Medicare and Medicaid Services (CMS) voluntary prior authorization pilot called the Wasteful and Inappropriate Service Reduction (WISeR) model. This will run in six states for six years beginning Jan. 1.
CMS knows there is a problem here, yet it has put massive constraints on the use of prior authorization in MA through a 2024 rule that forces the private plans to follow the traditional FFS Medicare program policies and largely prohibits the use of MA plan criteria even if evidence-based. In fact, hospital admissions are now the exclusive decision of providers and not plans. With more and more providers owned by hospitals, they are likely being ordered by their hospital bosses to conduct such surgeries whether needed or not.
The 2024 rule should be revisited given the results of the Lown analysis.
#medicare #medicareadvantage #priorauthorization
Humana Loses 2025 Medicare Advantage Stars Lawsuit
After having to refile its lawsuit on its 2025 Star ratings because it had not exhausted its appeals with the Centers for Medicare and Medicaid Services (CMS), Humana now has word on the merits of its case, and a federal court has rejected the health plan’s argument.
Humana sued CMS, arguing that the agency’s policy to not allow callbacks to the secret shopper on call center measures was arbitrary and capricious. The court said that CMS did not violate the Administrative Procedure Act (APA) by denying insurers opportunities to call auditors back if their connections were mistakenly dropped. O’Connor said that it is legal for CMS to not allow the callbacks.
The decision is rather definitive in my view and comes from a very business-friendly, agency-policy-skeptical judge who has a number of judgments against the agency, including the recent overturn of the Risk Adjustment Data Validation (RADV) audit rule.
The case was a bit unique in that Humana was arguing that callbacks must be allowed when calls are dropped, whether that occurred due to the plan’s failures or otherwise. Some plans are increasingly concerned on a similar issue – that CMS says it made calls to the health plans, but the plans have no record whatsoever of a call being made or a drop in its systems.
Additional articles: https://www.modernhealthcare.com/insurance/mh-humana-medicare-advantage-ratings-lawsuit-lost/ and https://www.healthcaredive.com/news/humana-medicare-advantage-star-ratings-lawsuit-dismissed-again/802739/ and https://www.beckerspayer.com/legal/judge-rebuffs-humanas-renewed-star-ratings-suit/
(Some articles may require a subscription.)
#cms #stars #medicareadvantage #partd #pdp #quality
https://www.fiercehealthcare.com/payers/humana-loses-second-legal-challenge-ma-star-ratings
Government Shutdown Drones On
For the eighth time, the Senate rejected a bill to reopen the government with no movement on Democratic support in the upper chamber. This means the government shutdown will enter its third week. The partis are not close to a deal, with Democrats still demanding healthcare concessions and Republicans wanting a clean continuing resolution or CR.
A new poll suggests that what was once a Democrat advantage on the shutdown issue may be turning against them. While Americans still blame the GOP more for the mess, a YouGov/The Economist poll shows the blame gap beginning to narrow. Only 6 points separate the parties, with 39% blaming President Trump and the Republicans in Congress for the shutdown, while 33% blame the Democrats in Congress. This is down from an 11% gap. About 20% now blame both sides equally. With a majority calling out both parties in some way, the spectacle appears to be helping neither party.
Additional article: https://thehill.com/homenews/house/5555904-poll-blame-democrats-shutdown/?tbref=hp
#governmentshutdown #trump #congress #healthcare #coverage
https://thehill.com/homenews/senate/5555466-shutdown-senate-bill-reopen-government
— Marc S. Ryan
