In this edition:

• ⛔️ MA Insurers deny 3.4 million

• 🐏 Proposal gives way for rural hospital success

• 🫀 Data shows concerning drop in number of Cardiologists

• 👎 Primary care physicians reluctant to join value based programs

• And more!

MA Insurers Denied 3.4M Prior Authorization Requests

Medicare Advantage insurers received about 46.2 million prior authorization requests in 2022, up from 36.5 million in 2021, according to a recent KFF report. Of these 46.2 million requests, 7.4% (3.4 million) were fully or partially denied by MA insurers, compared to 5.8% in 2021.

KFF’s analysis used data submitted by MA insurers to the Centers for Medicare and Medicaid Services. Just about all MA enrollees have to receive prior authorization for certain services, like higher-cost services, inpatient hospital stays and chemotherapy.

However, the practice has come under fire recently, with lawmakers and other advocates saying it delays care and burdens physicians. To address these concerns, CMS has finalized three rules that aim to make the process more efficient and clarify the criteria for prior authorization.

The KFF researchers also found that of the prior authorization requests that were denied, only 9.9% were appealed in 2022. This is similar to previous years, with just 10.6% of denials appealed in 2021.

Proposal gives way for rural hospital success

A newly introduced bipartisan bill, the Physician Led and Rural Access to Quality Care Act,  aims to loosen restrictions on physician-owned hospitals. 

The bill –– introduced by Reps. Michael Burgess, MD (R-Texas), Tony Cardenas (D-Calif.), Morgan Griffith (R-Va.), and Vicente Gonzalez (D-Texas) –– seeks to expand the existence of existing physician-owned hospitals, according to an Aug. 14 article published by the American Medical Association. 

The growth of physician-owned hospitals has slowed dramatically since 2010, according to the AMA, which cites the passage of the Affordable Care Act and a hospital-lobbied provision within the law that prevented any new physician-owned hospitals from opening.

Data shows shortage of Cardiologists

Nearly half of all U.S. counties don’t have a practicing cardiologist on staff, according to a recent study published in the Journal of the American College of Cardiology (JACC).

Rural communities are most affected, with Americans in those areas dying earlier and more often from heart disease that could have been prevented, according to a May report from the Centers for Disease Control and Prevention (CDC).

The study, led by Brigham and Women’s Hospital in Boston, analyzed over 3,100 counties.

Forty-six percent of the counties did not have access to cardiologists — meaning that 22 million residents would not have access to heart-related health care.

When looking just at rural counties, more than 86% of them did not have a cardiologist.

Why Primary Care Physicians Are Reluctant To Join Value-Based Care

While value-based payment models seem great in theory, research shows that many primary care providers aren’t partaking in these models.

Over the last 14 years, the Centers for Medicare and Medicaid Services (CMS), as well as several states, have introduced value-based care models directed at primary care.

The goal is to move away from the fee-for-service model — in which care is paid for by the volume of services — and instead tie payment to the quality of care provided and the ability to bring down costs.

Yet, only 46% of primary care physicians receive value-based payments, according to a 2022 survey. And smaller practices with less resources are even less likely to participate in value-based care.

According to one focus group participant, “When I hear the term [value-based payment], I think ‘great on paper, impossible to implement in reality.’”