AHA and AMA Sue Government over Surprise Billing Law

Last December's surprise billing law goes into effect in January 2022, and HHS has been rolling out regulations and guidance documents.  Generally, it caps payments to out of network providers at the median of a payer's in-network rates.  360Dx had an August subscription article on implications for labs (here).

New news.  AMA and AHA file a lawsuit against HHS regarding misguided implementation of the law.

• Press release here.
• AMA says No Surprises Act bad, here.
• Kaiser Health News here.
• Fierce Healthcare here.
• Healthcare Finance News here.

One of my takes on this is that it changes the "game theory" of contracting.  Let's say a health plan contracts with one hospital at $100, another at $125, another at $150.  Health plan could drop the top two hospitals from network, and contract with only the $100 hospital.  Then the second and third hospital will get paid by law at the $100 median in network rate, without bothering to contract with them.   Just an example.  The actual rules are complex.  Labs have faced contracting network strategy games for years - do you want to bill $100 out of network, hoping to get paid 50% or $50, but maybe zero, or do you want to contract in network for $45 you can count on reliably?  

See a mid-November article at NPR, "Doctors mad at surprise billing rules," with strong comment from Secr. Becerra that the law is good and will stop over-billing by certain providers.

Surprise Billing Law

Telemedicine surprise can get unexpectedly caught in the Surprise Billing Law.   What if you're an out of network telemedicine provider and charge $100 for 30 minutes, but the payer's in-network rate is $15 for 30 minutes?   See an article at HealthcareFinance here.  See an earlier note from McDermott here.

Expanding Medicare Telehealth: S.2343, "Telehealth Innovation and Improvement Act of 2015."

Sen Gardner of Colorado has introduced the Telehealth Innovation and Improvement Act of 2015, with press releases on December 2 and, after a delay, the actual legislative text is posted at Congress.gov.

The Top Ten Health Issues of 2016: From Price Waterhouse Cooper

PWC Health Research Institute:

HRI’s top 10 health industry issues for 2016

#1-#5: Mergers, drug prices, apps, cyberscurity, deductibles.

#6-#10: Behavior, community care, big data, biosimilars, and value-based costing (not purchasing).

Details and links after the break.

Larry Kricka's 20 Page Review of the History and Future of Laboratory Medicine

Approach the end of 2015, we can turn to 2016 by taking a look at a fascinating article that appeared a few months ago.

Larry Kricka, professor of pathology and laboratory medicine at Penn (here), is first author of four on the review and opinion article, "The Future of Laboratory Medicine: A 2014 Perspective," which appeared as an Invited Critical Review in Clinical Chimica Acta 438:284-303.   It is online (subscription or article purchase) here.

Kricka opens by citing a 1920 prediction that someday, there might be "as many as two lab workers" at major hospitals (here).

Bringing Genomics into the Clinic: Explaining Complex Issues

Genomeweb's Turna Ray has written a detailed article on the pathway from genomics discovery and genomics laboratory to the clinic.  It's mixed news, in that things seem to be getting better, but there's still much to be done.  The article is online here (subscription).

Just a couple years ago, Boehringer Ingelheim conducted a survey suggested that only 50% of lung cancer patients were getting basic genomic testing, like EGFR.  In a new survey, that number had risen to 81%.  However, due to delays in genomic test results, a significant proportion of patients are already started on non-precision chemotherapy even before their tests are back.

MEDPAC Touches Telehealth

Federal government policy on telehealth has advanced slowly, even as we all read about the rapid growth of a multi billion dollar industry.   For example, in 2012, the Institute of Medicine published a workshop on telehealth (here).

On November 5, 2015, the MEDPAC held a one hour session to update on the Medicare program and telemedicine.  Its concise "issue brief" is here, the PowerPoint deck here, and the 50 page transcript of the MEDPAC discussion is here.