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Boston Globe
a day ago
- Health
- Boston Globe
An attack on the medical establishment buried in an 1,800-page regulation
Medicare officials have been loath to change it because it has spared them from needing their own staff and budget to make such pricing decisions, along with the unpleasant politics of adjudicating conflicts between competing groups of physicians. But a change buried inside a 1,803-page proposed regulation published last Monday suggests the Trump administration would like to move away from this longstanding system. If finalized, it could begin overturning a process that has entrenched pay advantages for certain kinds of doctors. Get Starting Point A guide through the most important stories of the morning, delivered Monday through Friday. Enter Email Sign Up 'We're modernizing Medicare by correcting outdated assumptions in how physician services are valued,' said Chris Klomp, a deputy administrator of the Centers for Medicare and Medicaid Services, in an email. Advertisement Robert F. Kennedy Jr., the secretary of health and human services, has emphasized that medicine should focus more on primary care and prevention, and less on the treatment of advanced diseases. He has also crusaded against 'corporate medicine,' and has specifically criticized the American Medical Association. Stat News reported in November that Kennedy was considering policies to disempower the AMA committee. Advertisement Dr. Bobby Mukkamala, the AMA's president, was highly critical of the proposed change. 'The American Medical Association believes that proposals to exclude or limit the input of expert practicing physicians and health care professionals in the development of Medicare payment policy would ultimately harm patients and represents a radical departure from the time-tested CMS decision-making process,' he said in a statement. The current AMA committee, known as the RUC, uses data gathered in surveys of doctors to set formulas for every kind of medical care. The committee suggests payment rates to Medicare's regulators, who almost always adopt them. The system is effectively zero-sum — any increases for one kind of doctor represents decreases for others. While private insurers are free to develop their own formulas for paying doctors, they tend to follow Medicare's lead, making the committee very influential on what kinds of medical care get the largest (and smallest) financial rewards. The estimates are often outdated. Existing payments are reviewed on average only once every 17 years. A Washington Post investigation in 2013 reported on numerous gastroenterologists who had billed Medicare for more than 24 hours' worth of colonoscopies a day. The reason wasn't fraud. Medicare was still paying the doctors as if each test took 75 minutes to complete, when most doctors were able to complete one in 30 minutes. (The colonoscopy payment has since been adjusted.) Under the new proposal, Medicare would pay 2.5 percent less for every procedure, operation and medical test in 2026, based on data suggesting there have been improvements in 'efficiency' over the years. Payments for treatments based only on time, like a consultation with a family physician or neurologist, would not be cut. Such adjustments would be repeated every three years. Advertisement The proposal also looks to change the kind of data Medicare should consider instead of the relatively small surveys, noting that new sources of health data from hospitals and electronic billing systems could offer more accurate information. The effort to adjust what doctors are paid for their work is just one part of the large rule, which also contains provisions to broaden coverage for telemedicine, pay for more mental health care, and reduce overpayments for a new and expensive type of skin bandage. One other provision, meant to better account for the costs of running a medical practice, also affects the relative pay of different medical specialists. In some cases, those changes would reduce payments to the types of medical specialists whom the efficiency adjustments are meant to benefit. That policy would adjust payments to doctors based on whether they offer services on a hospital campus or in a private practice office, effectively lowering payments in the hospital and boosting those elsewhere. Taken together, the overall proposal would do more than just increase the salaries of primary care doctors. It would also increase the average pay of an allergist next year by 7 percent, and decrease pay for a neurosurgeon by 5 percent, according to estimates published by Medicare. It would lower pay by 6 percent for infectious disease specialists, who tend to earn low salaries and perform few procedures -- and increase average pay for vascular surgeons by 5 percent. Dr. Adam Bruggeman, a spine surgeon in San Antonio who leads the council on advocacy for the American Academy of Orthopaedic Surgeons, said he was sympathetic to arguments that the current system may be paying for some medical procedures inaccurately. But he said the proposal — which would cut payments for all procedures next year — was too crude a solution to that problem. He described the 'efficiency' changes as 'taking an ax to the whole thing.' Advertisement 'We're just fighting an arbitrary number with another arbitrary number, and that doesn't help,' he said. This article originally appeared in
The Hill
6 days ago
- Health
- The Hill
Trump administration takes shot at hospitals
The proposal takes a direct shot at the hospital industry, which has long opposed so-called site neutral plans. Hospitals currently get reimbursed more for off-campus outpatient care than physician offices or ambulatory surgical centers, a source of significant frustration for some lawmakers and fiscal hawks who argue equalizing the payment rates would save taxpayers billions of dollars. Bipartisan site-neutral plans were debated in Congress last year with the hope of being included in a year-end spending deal, but a deal did not materialize. In a proposed rule issued Tuesday, the Centers for Medicare and Medicaid Services (CMS) took a significant step in that direction. The agency proposed reducing payments for outpatient drugs delivered in hospitals and off-campus facilities. CMS said the move will help ensure beneficiaries aren't penalized with additional copays 'simply based on where they receive care.' The agency estimated the site-neutral provision would reduce outpatient spending by $280 million; Medicare would save $210 million, and Medicare beneficiaries would save $70 million in the form of reduced coinsurance. The American Hospital Association pushed back on the proposal. 'Studies show hospital outpatient departments are more likely to serve Medicare patients who are sicker, more clinically complex, and more likely to be disabled or living in poorer, rural communities than patients treated in independent physician offices,' the group said in a statement.
Axios
7 days ago
- Health
- Axios
Medicare proposes $8.1B boost for hospital outpatient care
The Trump administration wants to boost Medicare payments for hospital outpatient services by $8.1 billion next year — while simultaneously decreasing hospitals' reimbursement for services like chemotherapy. Why it matters: The payment proposal reveals that the administration is pushing hard for site-neutral reimbursements, or paying the same rate for services regardless of whether they're delivered in hospital outpatient facilities or doctors' offices. Hospitals typically bill Medicare more for the same services. Health systems have successfully lobbied against similar proposals in Congress in recent years. State of play: Hospital outpatient departments overall could expect a 2.4% increase in their Medicare payments, mostly due to an increase in the index that the Centers for Medicare and Medicaid Services uses to measure changes in prices. But Medicare administrators want to decrease what they pay hospitals to administer outpatient drugs at off-campus facilities, including chemotherapy, to make the sums equal to what is paid to physicians in private practices. This year, Medicare pays physician offices around $119 for a chemotherapy infusion, while off-site hospital outpatient facilities collected about $341, per the proposal. What it says: "We believe that financial incentives have driven volume from the office setting to the higher paying [outpatient department] setting, creating unnecessary increases in the volume of OPD services," the proposed rule states. CMS expects the change to decrease Medicare patients' cost-sharing by $70 million in 2026, and to reduce Medicare spending on hospital outpatient services by $210 million. The American Hospital Association called the proposal "inadequate." "We oppose the proposal to expand 'site-neutral' cuts and eliminate the inpatient-only list, as both policies fail to account for the real and crucial differences between hospital outpatient departments and other sites of care," Ashley Thompson, senior vice president of public policy analysis and development, said in a statement. CMS also wants to phase out over three years the list of services Medicare will only pay for when delivered in an inpatient setting. Medicare created the list in 2000 on the premise that some procedures could only be safely delivered at an inpatient hospital. The list currently includes 1,731 procedures. CMS proposed eliminating the list in 2021 but ultimately decided not to. Now, the agency says it's decided that innovations in medicine have made outpatient procedures much safer. "We agree with past commenters that the physician should use clinical knowledge and judgment, together with consideration of the beneficiary's specific needs, to determine whether a procedure can be performed appropriately in a hospital outpatient setting or whether inpatient care is required for the beneficiary," the proposal says.
Business Insider
16-07-2025
- Health
- Business Insider
CMS announces proposed rules for hospital payments in 2026
The Centers for Medicare and Medicaid Services issued the 2026 hospital outpatient prospective payment system and ambulatory surgical center payment system proposed rule. This proposal introduces 'a series of patient-focused reforms that would modernize payments, expand access to care, and enhance hospital accountability,' the agency said in a statement. CMS says the proposed changes are designed to: Reduce out-of-pocket costs for Medicare beneficiaries; Expand choices in where patients can receive care; Increase hospital accountability and transparency; and Safeguard the Medicare Trust Fund from waste and abuse. 'CMS seeks to equalize payments for certain services delivered in hospitals and off-campus facilities, helping ensure beneficiaries aren't penalized with additional copays simply based on where they receive care. The rule also proposes phasing out the inpatient-only list, which would give physicians greater flexibility to determine the most clinically appropriate setting for care and allow more patients to choose outpatient surgical options,' it added. Publicly traded companies in the hospitals space include Community Health (CYH), HCA Healthcare (HCA), Tenet Healthcare (THC) and Universal Health (UHS). Elevate Your Investing Strategy: Take advantage of TipRanks Premium at 50% off! Unlock powerful investing tools, advanced data, and expert analyst insights to help you invest with confidence. Make smarter investment decisions with , delivered to your inbox every week.
Business Insider
15-07-2025
- Health
- Business Insider
Organogenesis, MiMedx fall after CMS rule to cut skin substitutes spending
The Centers for Medicare and Medicaid Services announced a proposed rule 'that would increase quality care for Medicare recipients while significantly reducing unnecessary spending.' The 2026 Medicare physician fee Schedule proposed rule 'would advance primary care management through new quality measures, reduce waste and unnecessary use of skin substitutes, and introduce a new payment model focused on improving care for chronic disease management,' the agency said in a statement. 'CMS is proposing to improve the care of chronic diseases by reducing burdens associated with the integration of behavioral health treatment into advanced primary care management,' it added. CMS noted that Medicare spending on skin substitutes 'has had unprecedented growth,' rising from $256M in 2019 to over $10B in 2024, according to Medicare Part B claims data. 'CMS currently treats skin substitutes as biologicals for the purposes of Medicare payment, which can reach as high as $2,000 per square inch. CMS is proposing to pay for skin substitutes as incident-to supplies, a change expected to reduce spending on these products by nearly 90%.' Shares trading lower following the CMS proposed rule include Organogenesis (ORGO) and MiMedx (MDXG). Elevate Your Investing Strategy: Take advantage of TipRanks Premium at 50% off! Unlock powerful investing tools, advanced data, and expert analyst insights to help you invest with confidence. Make smarter investment decisions with , delivered to your inbox every week.
