CMS (Centers for Medicare & Medicaid Services) recently reported that, “Biden-Harris Administration Takes Historic Action to Increase Access to Quality Care.” Their latest Final Rule defines quality in health care and establishes what the feds will pay for and what they won’t. From a care provider’s perspective, the new rules are so unrealistic as to be the final straw that breaks the camel’s back.

The new Final Rule has four major elements.

• Wait times to see primary care physicians or mental health specialists;

• Acceptable MLRs (medical loss ratios);

• Defining quality across the spectrum of CMS activities;

• Staffing ratios in nursing homes.

CMS establishes a maximum allowable wait time for an appointment with a primary care provider of 15 business days, and 10 business days to see a mental health provider. Services rendered after the maximum allowable wait time will not be paid. 

In 2017, average maximum wait time for a primary care appointment in a medium-sized city was 122 days. By 2024, wait times had increased another eight percent, to 132 days. The Final Rule requires an 89% reduction in maximum wait time or no payment. 

Meeting Biden’s standards is impossible. My personal primary care provider had a list of 900 patients. If she sees one patient every 15 minutes and works for fifteen hours non-stop (no food or bathroom breaks), she can see 60 patients per day. Working 15 days straight, she can see all 900 patients on her list within the maximum allowable. Of course, she would have to keep doing this indefinitely as Patient #1 would be due for another visit on day 16. Errors would be inevitable with only 15 minutes for each patient; there is no time to study or even think. What if a patient is late? And what about physician starvation or simple exhaustion?

The standard cannot be met, especially not with a shrinking number of care providers and an ever-increasing number of patients covered by CMS programs, now including illegal residents. Failure to meet the (impossible) standard means providers will not be paid. They can either quit or, more likely, stop seeing CMS-covered patients. 

Medical loss ratio (MLR) is defined as the “share of total health care [insurance] premiums spent on medical claims and efforts to improve the quality of care.” Ironically, what is called “loss” — the amount they spend on patients — is the reason to have health insurance.

The new Final Rule allows CMS bureaucrats to determine, case-by-case, what “acceptable” MLRs are for different insurance companies. In theory, an acceptable MLR for a company with a high-risk population is different from one that covers a low-risk group. In the real world, this rule allows the federal government to pick winners and losers based on who is in favor with Washington and who is not. Solyndra anyone?

One-size-fits-all doesn’t work. Everyone knows this except Washington. Their Final Rule creates definitions of high and low quality across the great differences between states, individual patients, and locally resources. Compare an “allowable” trauma response time for an automobile accident victim in Providence, RI with one in Helena, MT. There are three world-class trauma centers within a 45-minute drive of Providence. The nearest Level I trauma center to Helena is in Salt Lake City, UT, an eight-hour drive, assuming the roads are passable.

Staffing ratios in nursing homes — patients per nurse — are another unrealistic mandate.  The CMS rule requires 5.93 hours of direct care nursing per patient per day. Add the hours of mandatory regulatory compliance and insurance administrative requirements, and a nursing home needs at least one nurse per patient. Considering vacations and illness, a 40-bed nursing home would need at least fifty nurses on staff. 

With a shortage of nurses that rivals doctors, nursing homes cannot possibly find, much less afford one-nurse-per-patient ratios “acceptable for [CMS] payment.”  Nursing homes that do not meet the standard won’t be paid — that’s what the rule says. So, the result of the new standard will be closure of nursing homes. The ones that stay open will either falsify their reports to CMS or acquire special friends in Washington.

Unrealistic mandatory healthcare standards written by Washington will make medical care even less accessible than it is now. Where will CMS patients go when there are no primary care physicians and when all the nursing homes are shuttered?

Deane Waldman, M.D., MBA is Professor Emeritus of Pediatrics, Pathology, and Decision Science; former Director of the Center for Healthcare Policy at Texas Public Policy Foundation; former Director, New Mexico Health Insurance Exchange; and author of the multi-award winning book Curing the Cancer in U.S. Healthcare: StatesCare and Market-Based Medicine.

Image: Free image, Pixabay license.