November 2-3, 2023

11/02/2023 . 10:15 am - 11:30 am

Mandated report: Rural emergency hospitals

Staff Contacts:

ISSUE:  To help ensure access to emergency care in rural areas, the Commission recommended in 2018 that Medicare create a new category of hospital: an outpatient-only facility with a 24/7 emergency department. Consistent with the Commission’s recommendation, the Congress created the new rural emergency hospital (REH) designation in the Consolidated Appropriations Act (CAA), 2021. The CAA, 2021, also requires the Commission to report annually on payments to REHs, beginning in March 2024.

KEY POINTS:  Hospitals can convert to REH status beginning in 2023. REHs no longer maintain inpatient beds but provide 24/7 emergency services. REHs are paid 105 percent of standard outpatient prospective payment rates for emergency and outpatient services and receive a fixed, monthly payment from Medicare to help support the costs of maintaining a 24/7 emergency department. A small number of hospitals have converted to REH status to date. Because the REH program began in 2023, complete REH claims data are not yet available.

ACTION:  Commissioners will review information on the REH designation and the number and types of hospitals that have converted to REHs to date.

11/02/2023 . 11:35 am - 1:00 pm

Mandated report: Dual-eligible special needs plans

Staff Contacts:

ISSUE:  The Bipartisan Budget Act of 2018 directs the Commission to periodically compare the performance of Medicare managed care plans that serve beneficiaries who have both Medicare and Medicaid coverage. Many of the plan types we are asked to compare are particular variations of the dual-eligible special needs plan (D-SNP), which is a specialized Medicare Advantage plan for dual-eligible beneficiaries.

KEY POINTS:  D-SNPs vary in their level of integration with Medicaid and a majority of enrollees are in plans with relatively low integration. We used HEDIS clinical quality measures and CAHPS patient experience measures to compare plans and found they provide limited insight on plans’ relative performance.

ACTION:  Commissioners will review information about D-SNPs and their performance on quality and patient experience measures.

11/02/2023 . 2:15 pm - 3:25 pm

Hospice: MedPAC workplan

Staff Contacts:

ISSUE:  The Commission has several new and ongoing projects concerning hospice and end-of-life care.

KEY POINTS: Hospice provides palliative and supportive services for terminally ill beneficiaries who choose to enroll. Overall, nearly half of Medicare beneficiaries who die receive hospice services. The Commission’s workplan over the next eighteen months includes new or ongoing projects in several areas including: (1) hospice’s effect on net Medicare spending, (2) the hospice aggregate cap and beneficiary outcomes, (3) nonhospice spending for beneficiaries enrolled in hospice, and (4) use of hospice and palliative care among beneficiaries with end-stage renal disease.

ACTION: Commissioners will review the workplan and provide feedback.

11/02/2023 . 3:30 pm - 4:45 pm

Medicare coverage of and payment for software as a medical service: An overview

Staff Contacts:

ISSUE: Software is becoming increasingly important and pervasive in healthcare.

KEY POINTS: Medicare covers and pays for certain types of medical software that receive approval or clearance by the Food and Drug Administration. The software that we discuss in this session generally stands apart from hardware (i.e., software that is used for one or more medical purposes to diagnose or treat an illness or injury without being part of the medical service).

ACTION: Commissioners will provide feedback on the material presented.

11/03/2023 . 9:00 am - 10:25 am

Favorable selection in Medicare Advantage

Staff Contacts:

ISSUE:  Favorable selection into Medicare Advantage (MA) occurs when Medicare beneficiaries with actual costs below the cost predicted by their risk score are more likely to join MA than fee-for-service (FFS) Medicare. Because MA county benchmarks rely on FFS spending estimates, it is important that the FFS-enrolled population in each county continues to provide a reasonable basis for MA benchmarks, bids, and payments.

KEY POINTS:  New analysis finds consistent favorable selection in MA, which suggests that MA payments are far higher than comparable FFS spending.

ACTION:  Commissioners will review and discuss the findings.

11/03/2023 . 10:30 am - 12:00 pm

Evaluating access in Medicare Advantage: Network management and prior authorization

Staff Contacts:

ISSUE:  It is important for the Medicare program to ensure that beneficiaries have access to high-quality health care in Medicare Advantage (MA), and that program resources are used efficiently. Stakeholders have raised concerns about the use of provider networks and prior authorization to manage access to care in MA.

KEY POINTS: We review how network management and prior authorization are used by MA plans, how CMS regulates the use of these tools, and the data that MA plans currently report in these areas. We identify potential opportunities for further analysis.

ACTION:  Commissioners will discuss the material and provide guidance on future work.