Yesterday, November 20, the bell rang. CMS issued its proposed rule on insurance exchanges and their requirements. CMS essentially has reaffirmed what the ACA requires. This is not unexpected, but it demonstrates how the “sturm and drang” of the dialogue pre-2012 election has now officially been replaced with a certain normality as the proposed rules are released, reviewed, and then made final. Don’t expect these proposed rules to change much.
The quick take-aways are:
- Whether state or federally run, or a mix, the all-important insurance exchanges will not be able to deny coverage and will not be able to charge certain types of patients (women, people with pre-existing conditions) more for coverage. Remember – CMS just gave the states an additional four (4) weeks to consider to what extent they wish to have the federal government involved in running their individual state exchanges.
- One of the “quid pro quos” of the ACA – that as the number of covered lives is increased, other types of payments to hospitals for caring for the uninsured (e.g. the DSH payments) fade away over time – remains unchanged and is now on track.
- In the exchanges, insurers will have to cover 10 “basic” health care benefits – such as ER care, maternity care, prescriptions, and hospital stays.
It will be interesting to see in what direction states that have not yet made a choice as to their exchange model choose to go.
In its OPPS rule for 2013, CMS has asked for comments from hospitals as to whether there would be greater clarity “regarding patient status if there were more specific criteria for patient status in terms of how many hours a patient remains in a hosptial.” In other words, would a “bright-line” test of, say, 24 hours determine whether someone is an inpatient under all circumstances?
Clearly, the Recovery Auditors target “inpatient cases” becasue denials of inpatient status result in income for RACs.
It is possible that a bright line test would result in a change of emphasis from review of the setting to review of the appropriatness of medical necessity. Stay tuned – but comments are due September 4.
The recent issue of Scientific American, which I heartily recommend, contains a short but interesting article on the two primary ways of achieving even greater longevity than we have now. One, focus on the specific areas of the body that cause trouble and remove/regenerate/replace them. Two, and alternatively, examine molecular development way down at the molecular level to adjust cellular development in order to “slow down” the aging process. I am summarizing, of course, so read the article! But what strikes me is that while living beyond 100 years may be desirable for some, as a society we truly need to address how such lives will be led, and under what conditions for the participants – mentally, socially, and physically. Our medical and scientific knowledge, we should assume, will outpace our evolutionary and mental capacities for coping with this knowledge.