Wanna go on a road trip? It seems like a good time to get in the car, put on some great tunes, and just escape onto long, winding roads that go somewhere else. You can think about clouds in your coffee while you thoughtfully chew on Green Onions and go until you’re Running on Empty. No permission is necessary and not a lot of rules are involved in a road trip — which is not the case with healthcare right now. We explain in the One Thoughtful Paragraph below.
For now, the news this week is all about new rules:
- On November 6, 2023, CMS issued a proposed rule that would (in part) require Medicare Advantage plans to report more data on coverage decisions. The idea is for CMS to review why plans decide to pay or not pay for certain services and assess how it impacts health equity.
- CMS published the 2024 Hospital Outpatient Prospective Payment System (OPPS) final rule (but it is not scheduled to be published until people start thawing the turkey on Nov 22, 2023… coincidence?). The rule is designed (in part) to make hospital prices more transparent by requiring hospitals to use a CMS template for machine-readable files, standardize certain data elements, and comply with new enforcement provisions.
- CMS also released the 2024 Medicare Physician Fee Schedule final rule, which includes changes to the Medicare Shared Savings Program (MSSP) — a voluntary program that encourages providers (with money as the carrot) to collaborate with each other to coordinate care through value-based payment arrangements by creating accountable care organizations. The MSSP will encourage the use of more digital measures of clinical quality. Because the how-to-measure-quality process is not easy, CMS refers people to a fact sheet and a New England Journal of Medicine article that its leaders published back in February.
Road trips are good but tucking into a good movie is better. We are celebrating the end of the actors strike (rumored to be finally over), which will give writers the green light to work again (their strike ended in October). So who gives doctors and patients the green light to get medical treatment? Health plans. Why are health plans the traffic cop? Because they are the ones that agreed to pay for it, according to contracts they made with people (or their employers) and the doctors (or the hospitals) and the rest of the health care planet (pharmaceutical companies, pharmacies, medical device manufacturers, etc.). Seems like a lot of traffic to manage — which is why health plans use computers to make things go faster. With the spotlight on artificial intelligence, health plans’ decades-long use of computers (glorified electronic spreadsheets of what should and shouldn’t be paid for) is suddenly being called into question. If policymakers decide the red-yellow-green traffic light automated system doesn’t work, we had better be willing to sit in traffic (read: doctors should expect to wait for payment with more retrospective review processes). Yield for another CMS rule: The agency is poised to improve, not eliminate, the automated electronic prior authorization process with a final rule scheduled to be released any day now. Better turn on the tunes because we are in for a long ride.
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