This month’s newsletter includes an update on the litigation between the Texas Medical Association and the federal government over the rulemaking for medical bill dispute resolution, insight about effective ways to use new opioid settlement money coming to Texas, and a report showing the significant economic impact of hospitals in North Texas.
Thanks for reading!
Eli Kirshbaum
State of Reform
1. Texas providers continue to contest medical bill dispute resolution rules
The Texas Medical Association is again suing the federal government over its rulemaking for dispute resolution protocols for disputed out-of-network medical bills. In a lawsuit backed by AMA and AHA, TMA alleges that HHS’s final rule for Independent Dispute Resolution favors payors over providers by relying on the Qualified Payment Amount—despite TMA’s previous lawsuit alleging the same thing about HHS’s interim rules on the matter earlier this year.
A federal judge sided with TMA in its lawsuit over the interim rules in February of this year, directing HHS to reformulate the rules to be less favorable toward insurers. TMA, however, views the federal government’s continued inclusion of the QPA in the final rules published in August as still biased. “Like the invalidated QPA presumption, these new requirements unlawfully elevate the QPA over the other statutory factors, making the QPA the de facto benchmark rate,” TMA said.
2. SUD advocate urges new settlement money to be directed to new prevention strategies
In addition to the $4 billion it’s received from national opioid settlements since 2020, Texas is slated to receive $276 million more from a recent $5 billion multi-state settlement. Aaron Ferguson, Regional Outreach Manager at Community Medical Services, believes this money needs to be used to pursue new SUD treatment strategies, saying current state policy is perpetuating opioid abuse.
“Some of the most evidence-based policies that we can be implementing right now are not currently allowable, by law,” Ferguson told State of Reform. “So we have to operate within the framework of what we have.” Ferguson said the money should be used to implement programs like safe injection sites and clean needle distribution—initiatives that are currently prohibited in the state.
3. What They’re Watching: Stephanie Muth, Stephanie Muth Consulting
In this edition of our “What They’re Watching” series, Stephanie Muth, former Texas Medicaid Director and currently a Principal at Stephanie Muth Consulting, says Medicaid redeterminations and addressing the social determinants are 2 of her top priorities.
“One of the projects that I’m currently working on is related to those non-medical factors, and trying to link food banks across the state with managed care organizations to better address the food insecurity issues,” Muth said.
4. North Texas hospitals contribute nearly $40 billion to region’s economy
A recent report from the Dallas-Fort Worth Hospital Council revealed that the council’s 97 member hospitals contributed $38.4 billion to the North Texas economy in FY 2022—25% more than they did 5 years ago. Member hospitals created 372,988 jobs in 2022 with a labor income of $26.3 billion, $1.4 billion from state and local taxes, and $4.4 billion from federal taxes.
“Hospitals act as economic engines and generate huge financial impacts for the communities they serve,” said Stephen Love, President and CEO of DFWHC. “In many cases, they are one of the largest employers in a community … The activities of the DFWHC-member hospitals are attracting [profitable] industries and must be recognized as a large contributor to the economy.” Love also said expanding Medicaid would support the continued economic success of North Texas hospitals.
5. Healthcare discussions during Congress’s lame-duck session
Significant healthcare policy decisions are often made after Congress adjourns for the year, as was the case last year with the passage of the No Surprises Act and other key policies. In his November column, State of Reform columnist James Capretta explores the healthcare reforms on the table for the 2023 lame-duck.
Capretta explains that Medicare reimbursement will be a central area of discussion, with suspension of the Medicare PAYGO Sequester and cuts to Medicare physician fees being probable. He also lists permanent extension of COVID telehealth parity rules and additional COVID funding as possible discussions.