Featured Guest: Scott Nelson (Host)

Highlights of recent headlines from the U.S. Department of Health and Human Services (HHS) and their potential risk considerations

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in. 

Oral health is often seen as just another aspect of our well-being, but it’s much more than that. It’s a gateway to our overall health, a crucial component that, if neglected, can lead to significant consequences. Today, I want to talk about something that’s been gaining momentum within the healthcare community: The CMS Oral Health Cross-Cutting Initiative. This initiative, led by the Centers for Medicare & Medicaid Services, is making strides to improve access to dental care and reduce disparities. But as with any major change, it comes with its own set of risks that must be understood and addressed.

Let’s start with the people most affected by this initiative.  This initiative impacts a wide range of individuals, from Medicare and Medicaid beneficiaries to healthcare providers and policymakers. Vulnerable populations, including the elderly, low-income individuals, and those with chronic health conditions, are particularly at risk. These are the people who rely heavily on Medicare and Medicaid for their dental care, and any missteps in this initiative could have serious consequences for them.

CMS has introduced new rules allowing dental services to be covered when they are inextricably linked to other medical treatments. This is a positive development, but it also brings complexity. There’s a real risk that misinterpretation of these policies could lead to delays or denials in treatment, leaving patients to suffer unnecessarily. Vigilance is needed to ensure that these policies are implemented correctly and that patients receive the care they need, when they need it.

Another significant change is the expansion of dental codes under the Hospital Outpatient Prospective Payment System and the Ambulatory Surgical Center final rule. This change is designed to increase access to dental services, but it also places a new administrative burden on healthcare providers. Navigating these new regulations can be overwhelming, and any errors could result in financial penalties for healthcare organizations or out-of-pocket expenses for patients. The stakes are high, and the margin for error is small.

These risks can arise at various stages—from the initial rollout of new policies to their ongoing administration. As states begin to adopt updated Essential Health Benefits benchmarks that include routine adult dental services, there will inevitably be a period of adjustment. During this time, confusion and miscommunication can easily occur, especially among providers who need to adapt to new billing codes and coverage criteria. Preparations must be made for this transition and ensure that systems are ready to handle these changes without compromising patient care.

The risks associated with this initiative are not confined to any one area; they permeate every level of our healthcare system. From small dental practices to large healthcare organizations, everyone is affected. At the state level, the challenge is integrating these new initiatives into existing programs. States that struggle to do so may find themselves delivering inconsistent care, which undermines CMS’s goal of eliminating disparities in oral health.

So why do these risks exist? The answer lies in the complexity of the initiative itself. CMS is moving to implement these changes, but the healthcare system is vast and intricate. New billing codes, coverage rules, and quality measures all require significant adjustments from everyone involved. Any misalignment between CMS’s intentions and the reality of implementation can lead to unintended consequences—gaps in care, financial strain, and, ultimately, patient harm.

Moreover, CMS’s focus on data collection and analysis, while crucial for long-term improvements, can uncover systemic issues that demand immediate attention. This creates a reactive environment where healthcare providers and organizations are constantly trying to catch up, increasing the likelihood of errors and adverse events.

But there’s good news. We can manage these risks by staying informed and proactive. Education and training are key. Healthcare providers and organizations must prioritize continuous learning to keep up with the latest CMS regulations and understand their practical implications. Collaboration is also critical. Open communication between state programs, healthcare providers, and other stakeholders will help identify and address potential risks early on, before they escalate.

Investing in data management systems is another important step. By leveraging data analytics, we can track and analyze oral health outcomes in real time, allowing more informed decisions and mitigating risks more effectively. This not only helps manage immediate risks but also contributes to the long-term success of CMS’s Oral Health Cross-Cutting Initiative.

CMS’s Oral Health Cross-Cutting Initiative represents a step forward in improving access to dental care and reducing disparities. But with this progress comes a responsibility to manage the risks that accompany such major changes. Now is the time to review practices, update training programs, and engage with CMS resources to stay ahead of the curve. Stay informed, stay prepared.

As we consider the evolving landscape of healthcare, it's clear that challenges faced by the dental sector under the CMS Oral Health Cross-Cutting Initiative are not unique. The complexities of integrating new policies and ensuring equitable access to care resonate across the entire healthcare system. Just as dental practices are grappling with new regulations and the risks they bring, the broader medical community is facing change with the introduction of the "Physician Fee Stabilization Act." Both sectors are navigating changes that aim to stabilize and improve care, but with these changes come significant risks that must be carefully managed to ensure that the intended benefits reach those who need them most. As we transition from discussing the specific risks in dental care to those in the medical field, it becomes evident that the strategies and vigilance required to address these challenges are interconnected and critical for the future of healthcare as a whole.

The recent introduction of the "Physician Fee Stabilization Act" in the Senate, which followed HR 6545, is a step toward ensuring a more predictable future for physicians and healthcare organizations. This legislation aims to increase the budget neutrality threshold under the Medicare Physician Fee Schedule from $20 million to $53 million by 2026. It also seeks to align this threshold with the Medicare Economic Index, creating a system that better reflects the true costs of providing care.

On the surface, these changes seem like a much-needed relief for providers who have long been burdened by the threat of sudden, across-the-board cuts. But as we delve deeper, we must acknowledge the potential risks that come with such sweeping reforms.

Who is Impacted? The stakes are high for physicians, healthcare organizations, and most importantly, the patients we serve. Physicians are directly impacted, as their reimbursement rates determine not only their financial stability but also their ability to continue providing care. Healthcare organizations, particularly those operating on tight margins, could face significant challenges if these reforms don’t play out as planned. And let’s not forget the patients—who may ultimately bear the brunt of any disruptions in care that arise from financial instability among providers.

What is the Impact and Potential Risk? The primary risk is financial instability for healthcare providers. While the "Physician Fee Stabilization Act" is designed to prevent drastic cuts to physician payments, the implementation of these changes could be fraught with challenges. If the new thresholds and indexing mechanisms do not accurately capture the real costs of care, providers could face shortfalls that force them to reduce services, limit patient access, or, in some cases, close their doors altogether.

Additionally, the complexity of these reforms—such as the introduction of regular updates to practice costs and a two-year look-back period for correcting utilization misestimates—adds another layer of administrative burden. This could strain already overtaxed systems, leading to errors, delays in reimbursement, and increased operational costs, further exacerbating financial challenges.

When Might Risk be Encountered? These risks could surface at various stages—from the initial rollout of the new budget neutrality threshold to the ongoing adjustments required to align with the Medicare Economic Index. The introduction of new regulatory requirements could also pose challenges as healthcare providers and organizations work to adapt their operations to meet the new standards.

Particularly during the implementation of the two-year look-back period, providers may experience delays in reimbursement adjustments. This uncertainty could be especially challenging for smaller practices and rural healthcare providers, who may lack the resources to absorb financial shocks during this transition.

Where is the Risk? The risks are widespread but are particularly pronounced in smaller practices, rural healthcare settings, and regions with higher populations of Medicare beneficiaries. These providers are often more vulnerable to financial fluctuations, and any delays or inaccuracies in reimbursement could have immediate and severe impacts on their operations.

Larger healthcare organizations might face risks in the form of administrative challenges. Implementing new systems and processes to comply with updated Medicare payment structures could lead to increased costs and inefficiencies, affecting not only financial performance but also patient care.

Why is There Risk? The complexity and scope of the proposed changes are the primary reasons for these risks. The healthcare system is vast, and altering its payment structures involves multiple layers of regulatory, financial, and operational adjustments. Misalignment between policy intentions and practical implementation can lead to unintended consequences—gaps in care, financial strain, and potentially, patient harm.

Moreover, these reforms are being introduced in an already challenging landscape. Rising costs and workforce shortages have stretched healthcare systems thin. The additional burden of adapting to new Medicare payment rules could push some providers to the brink.

How Will There Be Risk, and How Should It Be Addressed? These risks will emerge through a combination of financial pressures, administrative challenges, and the unpredictability of healthcare delivery. To address and manage these risks, we must be proactive.

Continuous education and training are essential. Healthcare providers should stay informed about the latest regulatory changes and understand their implications. Working closely with financial advisors and billing specialists will help navigate the new payment structures and avoid costly errors.

Collaboration among stakeholders is also critical. Healthcare providers, policymakers, and advocacy organizations must work together to identify potential issues early and develop strategies to mitigate them. Open communication will be key to ensuring smooth implementation and addressing any unintended consequences.

Finally, investing in robust financial management systems will help healthcare organizations handle the complexities of the new payment structures. These systems should be capable of tracking and analyzing financial data in real time, enabling providers to make informed decisions and manage risks more effectively.

The reforms to the Medicare Physician Fee Schedule represent an opportunity to stabilize physician reimbursement. However, these changes also bring new challenges that must approached with care and diligence. Now is the time to review practices, update training programs, and engage with resources available to help navigate these changes. 

Thank you for listening to The Risky Health Care Business Podcast. You can listen to all episodes from the resource center page of the SpringParker website, springparker.com, or click the Listen link in the show notes to listen and subscribe for free on your platform of choice. And remember, accelerating health care performance is achieved through creativity, not just productivity.