July 2, 2015
National UpdateMedicare cuts eliminated from final trade package
Congress last week passed a final package of trade bills that omitted Medicare payment cuts exceeding $700 million that had been included in an earlier version of the legislation—a win for physicians.
On May 22, the U.S. Senate passed legislation as part of a trade package that would have used Medicare funding to offset the costs of a trade adjustment assistance program. That version of the bill would have extended the current Medicare sequestration through 2024 and increased it by an additional 0.25 percent. The additional cut would have reduced Medicare payments to physicians, hospitals and other health care providers in 2024 by $700 million and redirected these funds to an unrelated trade program.
After several complicated procedural maneuvers in the U.S. House of Representatives and Senate that occurred throughout June, the Medicare cuts were eliminated from the trade legislation and replaced by a revenue offset.
This successful outcome can be attributed largely to efforts by the AMA and other health care groups, as well as bipartisan collaboration among members of the House, including the Doctors’ Caucus. The AMA will continue its efforts to prevent an extension of Medicare sequestration cuts from being used to offset the costs of other legislation.
The House of Representatives last week passed H.R. 1190, the Protecting Seniors’ Access to Medicare Act, by a vote of 244-154. The legislation, sponsored by Reps. Phil Roe, MD, R-Tenn., and Linda Sanchez, D-Calif., would repeal the Independent Payment Advisory Board (IPAB), a panel empowered to make payment and policy decisions that could adversely affect access to health care for millions of Medicare patients.
Similar to the now-repealed sustainable growth rate formula, the IPAB is an arbitrary system that relies solely on payment cuts to reduce Medicare spending.
The final bill, however, offset the cost of the legislation by cutting more than $7 billion in public health and prevention funding. As the bill continues to move through the legislative process, the AMA will work to replace those cuts with more appropriate offsets.
The AMA looks forward to working with Sen. John Cornyn, R-Texas, the sponsor of companion legislation in the U.S. Senate, and others to secure final passage IPAB repeal legislation and preserve seniors’ access to their physicians.
High blood pressure is the most common chronic condition for Medicare patients, and type 2 diabetes is one of the top five, according to the Centers for Medicare & Medicaid Services. Physicians explained how the AMA is tackling these two issues in recommendations (log in) to a U.S. Senate working group.
Senate Finance Committee chairman Sen. Orrin Hatch, R-Utah, and ranking member Sen. Ron Wyden, D-Ore., announced the bipartisan Chronic Care Working Group earlier this year, to be co-chaired by Sens. Johnny Isakson, R-Ga., and Mark Warner, D-Va.
The AMA’s recommendations were in response to the group asking how to improve outcomes for Medicare patients with chronic conditions. Through its Improving Health Outcomes initiative, the AMA is tackling type 2 diabetes and hypertension. The comments also addressed ways to improve care in rural areas and how telehealth can be used to improve treatment of chronic conditions. The working group is expected to review comments and meet with stakeholders during the next few months and possibly develop legislation later in the year.
Physician involvement in a special group of health IT leaders could help solve the electronic health record (EHR) system problem.
With its recent involvement in the Substitutable Medical Applications and Reusable Technology (SMART) Platforms project, the AMA is embedding the voice of physicians in efforts to make EHRs work better for physicians and patients. A key component of the SMART project is the development of an infrastructure that allows for free, open development of plug-and-play apps. Such apps are intended to increase cost-effective interoperability between health technology, including EHRs. Jesse M. Ehrenfeld, MD, member of the AMA Board of Trustees, will lend the physician voice to project.
The AMA continues to advocate for better EHRs and views the SMART project as a vital component in improving physicians’ satisfaction with the use of health information technology in patient care.
Learn more at AMA Wire®.
More and more practices across the nation are e-prescribing (eRx) medications, but the rate of prescribing controlled substances electronically is significantly lower. Physicians provided input on how the U.S. Drug Enforcement Administration (DEA) can break down barriers to electronic prescribing of controlled substances, and more physician input is needed.
Although eRx of controlled substances is viewed as a more secure method of prescribing these substances, in its current iteration, added technological requirements and workflow disruptions are impediments to physician participation. In 2010, the DEA released an interim final rule on eRx of controlled substances that outlined various requirements for physicians, including two-factor authentication and identity proofing. Five years later, the DEA is seeking industry feedback in preparation for a new round of rulemaking.
In a meeting with DEA officials, the AMA outlined its concerns, which had been highlighted in a 2010 joint comment letter (log in). The current requirements continue to be burdensome for physicians and have contributed to the low participation rates for eRx of controlled substances. Concerns include:
- Identity proofing. The current process to verify physicians’ identities is complex and must be performed for each location where a physician wishes to e-prescribe. The DEA should consider allowing physicians’ hospital credentialing to be used for identity proofing for eRx of controlled substances instead of having to use a separate process. The AMA also suggested the DEA engage with initiatives like the White House’s National Strategy for Trusted Identities in Cyberspace identity management program.
- Clearer guidance. Access controls and other process requirements are not clearly explained in the interim final rule. The DEA should further clarify, including examples, to help physicians understand exactly what is required to comply with eRx of controlled substances.
- Two-factor authentication. While authenticating through a combination of PINs, passwords and biometrics increases security, it also contributes to workflow disruptions and adds cost constraints for many physicians. The DEA should reexamine the scope of technology that is compliant with controlled substance requirements and evaluate if lower-cost, high-performing biometric devices (such as fingerprint readers on laptop computers and mobile phones) could be used for two-factor authentication.
- Audit requirements. The requirement for physicians to report a compromised authentication protocol within one business day of discovery is not practical. Additionally, the DEA should consider how health information technology vendors may support the review of audit logs.
- Compliant software. Currently there are about 12 products on the market that are compliant with eRx of controlled substances, and there is no central location where physicians may find a list of these products. The DEA should maintain an up-to-date list of all compliant products, including a clearly defined explanation of their functions and any fees associated with their purchase and maintenance.
- Meaningful use participation. The Centers for Medicare & Medicaid Services’ (CMS) meaningful use program currently does not count eRx of controlled substances toward a physician’s effort to meet the eRx objective. While this has been proposed in Stage 3, the AMA asked the DEA to work with CMS to expand the option for physicians who wish to include eRx of controlled substances in their Stage 1 and 2 participation thresholds.
- Fees and compliance costs. In addition to the costs of coming into compliance with eRx of controlled substances, there are monthly fees. As DEA registration fees ($731 for three years) are set to cover the costs of its diversion control program and eRx of controlled substances lowers the risk of drug diversion, the AMA urged the DEA to consider reducing DEA registration fees for registrants who are using eRx.
- Prescription drug monitoring programs (PDMP). Although the DEA does not have authority over state PDMPs, the AMA urged the agency to work with other agencies to encourage integration of state PDMP databases and electronic health records in order to improve the integration of these data into practice workflows and physicians’ clinical decision making.
What are your thoughts on eRx of controlled substances? Give your input and help provide the DEA with a wider perspective of participation issues. Please provide feedback on eRx of controlled substances, including:
- Major disincentives for physicians who wish to participate
- Changes to the current program requirements to increase uptake
- Practical, functional or cost issues that should be considered
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Issue Spotlight3 things the Supreme Court’s ACA ruling means for physicians
An AMA Viewpoints post by AMA President Steven J. Stack, MD.
The Supreme Court of the United States delivered an historic decision Thursday morning in King v. Burwell.
In a 6-3 decision, the justices ruled that subsidies should remain available for lower-income people who purchase their health insurance through the Affordable Care Act (ACA) marketplaces, regardless of whether their marketplace is maintained by the federal or state government.
This ruling affects physicians in three ways I’d like to highlight:
1. The decision supports our chief goal of helping patients stay healthy.
The Supreme Court’s ruling means that about 6.4 million people in the 34 states that did not create their own marketplaces will retain their ability to purchase coverage going forward. This is particularly important for low-income patients in states that did not expand their Medicaid programs. Without the subsidies, many of them could never afford health insurance.
As an emergency physician, I regularly see how important insurance coverage is to facilitate patients getting the medical care they need to recover from unexpected injury or illness. It also enables them to lead healthier, happier lives through better care of chronic diseases that can be devastating for them and their families.
The decision also means that insurance premiums will remain more affordable for most patients than would have otherwise been the case. A recent RAND study estimated that eliminating subsidies for patients who purchase their insurance through the federally run marketplace would result in a 47 percent increase in premiums. In such a scenario, a 40-year-old nonsmoker who purchased an unsubsidized silver-level plan would have needed to pay $1,610 more next year.
2. The decision lets us move forward.
With this case behind us, we as a profession and as a nation now must focus on the issue at the heart of health care reform: Ensuring every American has access to high-quality, affordable health care.
Regardless of differing opinions, access to high-quality, affordable health care is an issue we can all support. And by continuing to work together toward this end—whether through refining individual elements of the ACA, such as repealing the Independent Payment Advisory Board, or making changes to the current health care system—we can improve the health of all Americans.
3. The decision means we can turn our attention to improving the practice environment.
In moving forward, we must also devote our attention to transforming the practice environment so that both patients and physicians are healthier and more satisfied.
At the AMA, we’re working to enhance professional satisfaction and practice sustainability by pressing for relief from the tsunami of regulatory burdens that gets in the way of providing the highest-quality care for our patients. Among those burdens are the electronic health record meaningful use program, implementation of ICD-10 and the value-based payment modifier. Lawmakers, too, are now able to turn their attention to these pressing topics.
We’re also providing the tools physicians need to minimize professional stress and overcome barriers to providing the best possible care. Our newly launched STEPS Forward website offers a free online series of proven solutions that are developed by physicians to make practices thrive. We’ll be adding more modules over the coming months, so be sure to explore the website often.
Also, on the STEPS Forward website, we invite you to submit your own innovative solutions to clinical challenges to win $10,000 and help us create more modules to help physicians.
Even in these early years of health care reform, implementation of the ACA has affected much of the health care system. To examine this issue further, I encourage you to check out the July issue of the AMA Journal of Ethics, which takes a look at how patient care has changed in the era of health care reform.
State UpdateNCOIL to consider model bills on provider directories, telemedicine
State legislators who are responsible for insurance legislation will consider AMA model bills on provider directories and telemedicine.
The National Conference of Insurance Legislators (NCOIL) will consider:
- Model Act to Ensure Meaningful Access to Accurate Provider Directories. Sponsored by Arkansas Rep. Deborah Ferguson, this model would require insurance department approval of insurance company provider directories, as well as of annual updates. It also would identify various contact and other information that must be included in a directory, including whether physicians are accepting new patients and set rules for publishing and updating directories. Finally, it would lay out rules for enforcement and allow for private rights of action.
- Model Telemedicine Reimbursement Act. Sponsored by Rhode Island Rep. Brian Kennedy, this model would require coverage for telemedicine services that would be on par with coverage for in-person treatments. It also would, among other things, prohibit insurers from excluding coverage for a service solely because it is provided through telemedicine.
- Model Telemedicine Licensure Act. Also sponsored by Rep. Kennedy, this model would require physicians treating patients to be licensed in the state in which the patient receives care, as well as to be regulated by that state’s board of medicine.
Connecticut is the latest state to enact telemedicine pay parity laws based on AMA model bills.
Connecticut’s new model, which aligns with the AMA’s Telemedicine Reimbursement Act, provides that individual health insurance policies must cover medical advice, diagnosis and treatment provided through telehealth, to the extent coverage is provided through in-person coverage. In addition, the model prohibits an insurer from excluding a service solely because the service is provided through telehealth.
Connecticut’s new law also establishes some practical rules of the road for physicians who wish to provide medical care via telemedicine technologies, such as the need to obtain informed consent regarding the treatment methods and limitations of treatment using a telehealth platform. Four states now have enacted telemedicine laws based on AMA model bills. Visit the AMA state telemedicine Web page for more information on model telemedicine legislation.
Judicial UpdateCourt to weigh physicians’ right to payments, recourse
Should physicians be left holding the bag when a private insurer retroactively denies a medical claim or recoups a payment? A federal appeals court is considering a case that could determine whether medical providers have recourse in such situations to ensure that their practices remain financially stable so they can continue caring for their patients.
At issue in Pennsylvania Chiropractic Association v. Independence Hospital Indemnity Plan, Inc., is the payer retroactively denying benefits or taking back payments without explaining why the action was taken or how the medical provider can appeal the decision.
“The decades-long dispute continues between medical providers and the … third-party payers … of Employee Retirement Income Security Act (ERISA)-regulated health plans over whether providers should be paid for their services, and how providers can assert their right to receive payment,” the Litigation Center of the AMA and State Medical Societies and the Illinois State Medical Society said in an amicus brief recently filed with the court.
“Unsurprisingly, the position Independence Hospital Indemnity Plan takes would result in … medical professionals performing necessary medical services and then being left ‘holding the bag,’” the brief states.
Read more at AMA Wire.
Other NewsSunshine Act data released this week
The second release of physicians’ financial data under the Physician Payments Sunshine Act, also known as the Open Payments program, was Tuesday. Learn the three questions patients or others may ask physicians about their 2014 financial data and how to answer them.
Visit the AMA’s Open Payments Web page for additional resources, including detailed talking points (log in) to help explain the June 30 data release to your patients and step-by-step instructions for how to register to review and dispute your data.
If you weren’t able to review and dispute your financial data by May 20, you may see inaccuracies. However, you still can review and dispute errors, and corrections will be reflected in the next scheduled update of the database.
The current manual system of prior authorization transactions used in the health care revenue cycle harms patients and physicians, the AMA told the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards.
The AMA testified before the committee in June, providing feedback and recommendations on the currently mandated standard electronic transactions and urged the committee to address the multiple process gaps that are hindering automation.
In other testimony, the AMA highlighted the impact of enrollment hassles and health plan noncompliance on physician adoption of the electronic remittance advice and electronic funds transfer (EFT) transactions. The AMA argued that health plans’ use of virtual credit cards has prevented optimal implementation of standard EFT. The AMA also submitted written testimony summarizing concerns with and recommendations for the other electronic transactions. Visit the AMA’s administrative simplification advocacy Web page to access the oral presentation slides and written testimony.
State society political action committee (PAC) chairs and directors are invited to the annual AMPAC Federation meeting in Washington, D.C., Sept. 17-18 at the Grand Hyatt Washington.
The program will take place on Sept. 17 and the morning of Sept. 18. AMPAC encourages attendees to schedule meetings with their members of Congress on Sept. 17, preferably in the morning. Capitol Hill visits will be followed by lunch and fundraising training, discussion of innovative state programs, and a preview of the 2016 elections. The evening of Sept. 17 will feature a reception in honor of the guests.
The room block has been arranged for a Sept. 16 arrival and Sept. 18 departure. AMPAC will reimburse PAC directors and PAC chairs for two hotel nights each at the room block rate of $279. The room block is now open—make your reservation soon, as the block closes Aug. 17.
Please direct any questions to Jim Wilson of the AMA.
Participate in a free webinar at noon Eastern time that will explain how physician practices can adopt electronic remittance advice (ERA). “ERASE payment issues with ERA” will be hosted by practice management experts who will share advice for getting started, claims processing tips and free tools to equip your practice team. Register today.
Sign up for the 2016 AMPAC Candidate Workshop, which prepares those considering a run for public office. For more information or to apply, please see the online registration form or email Jim Wilson of the AMA.
Register for the 2016 AMPAC Campaign School, which is for AMA members who wish to become involved in the political process as advocates and volunteers for medicine-friendly candidates. For more information or to apply, please see the online registration form or email Jim Wilson of the AMA.
News You Can Use
Following is suggested content to use in your association’s communication vehicles beginning in January. Please email Terri Marchiori of the AMA to let us know if you’re placing this material, your distribution channels, the response from your members and any other metrics, such as audience reach.
- From MOC to vaccines: Top 10 stories from AMA Annual Meeting (log in)
- Real ways physicians are making their practices thrive (log in)
- 6 ways your practice can save by using electronic transactions (log in)
- Physician-tested tools can improve patients’ health (log in)
- New “third science” a bedrock for transforming med ed (log in)