November 23, 2015

National Update

Physicians urge CMS to adopt fundamental MACRA principles

Advocating for the Centers for Medicare & Medicaid Services (CMS) to adopt 10 fundamental principles as it develops regulations implementing the Medicare Access and CHIP Reauthorization Act (MACRA), the AMA was joined by more than 100 national medical organizations and state medical societies in a unified response (log in) to the CMS request for information (RFI) issued last month. Initially developed by the AMA MACRA Task Force, the principles call for:

The AMA also worked with specialty and state society staff on its two MIPS and alternative payment model (APM) workgroups to develop detailed comments on the RFI priority topics. These drafts were distributed to state and specialty medical societies in bullet form for use in their own comments, as well as being included in the AMA comment letter to CMS.

On the MIPS, the AMA comments underscore the need for the program to be flexible instead of one-size-fits-all. The comments also emphasize that the program should be truly value-based and meaningful to physicians, unlike the programs it replaces, which judge physicians according to quality and cost measures that are largely irrelevant to their practices.

Regarding APMs, AMA comments focus on the need for CMS to implement the proposals for physician-focused models that stakeholders propose. As with the MIPS, the AMA is concerned that CMS may go down the same road it has been on in the past. To date, most physicians still do not have access to Medicare payment models that provide the resources and flexibility they need to support provision of high-value care to their patients. Read the full letter and learn more.

New guide available on physician-focused payment models

The Medicare Access and CHIP Reauthorization Act (MACRA)—the legislation that repealed the sustainable growth rate (SGR) formula—created major new opportunities to advance implementation of alternative payment models (APM).

For services furnished from 2019 through 2024, MACRA provides a 5 percent annual bonus payment to physicians who participate in APMs, and it exempts them from participating in the Merit-Based Incentive Payment System (MIPS). In addition to accountable care organizations, medical homes and bundled payments for hospital-based episodes, MACRA also provides for the development of “physician-focused” APMs.

The AMA worked with Harold Miller at the Center for Healthcare Quality and Payment Reform, a member of the newly appointed Physician-Focused Payment Models Technical Advisory Committee to the federal government, to develop the “Guide to Physician-Focused Alternative Payment Models.” The seven different APMs described in this guide can help physicians in many different specialties redesign the way they deliver care in order to improve patient care and manage health care spending for the particular patients, conditions and episodes they treat. The models also potentially help physicians qualify for the APM annual bonus payments.

The guide provides examples of how the APMs are being used by different specialties and how they could be applied to diverse patient populations, including cancer care, cardiovascular care, chronic disease management, emergency medicine, gastroenterology, maternity care and surgery.

Physicians call on Congress to intervene in meaningful use Stage 2

Congress has introduced new legislation, H.R. 3940, the Meaningful Use Hardship Relief Act of 2015, to streamline the hardship exemption process.

In order to avoid a penalty under the meaningful use program, eligible professionals must attest that they met the requirements for meaningful use Stage 2 for a period of 90 consecutive days during calendar year 2015.

However, the Centers for Medicare & Medicaid Services (CMS) did not publish the Modifications Rule for Stage 2 of meaningful use until Oct. 16. As a result, eligible professionals were not informed of the revised program requirements until fewer than the 90 required days remained in the calendar year.

CMS has stated that it will grant hardship exemptions for 2015 if eligible providers are unable to attest due to the lateness of the rule. However, under current law, CMS can only grant such exemptions on a case-by-case basis. This means that many eligible professions will be required to apply for exemptions and that CMS will have to act on each application individually.

Introduced by Rep. Tom Price, MD, R-Ga., on Nov. 5, H.R. 3940 would grant CMS the authority to grant blanket hardship exceptions to physicians, hospitals and other affected providers for 2015, alleviating burdensome administrative issues for both providers and the agency. The AMA strongly supports this legislation and is working to have it passed by Congress this year.

Visit to submit comments about meaningful use to CMS and Congress.

Back to Top

Issue Spotlight

Physicians stand up against mergers of powerful insurers

Two marriages are in the works among the nation’s largest health insurers—and physicians are speaking up, refusing to forever hold their peace. The proposed mergers, which would reduce competition in the health insurance market, pose a substantial risk of harm to patients and physicians in terms of health care access, quality and affordability.

Health insurers have claimed that the mergers—Aetna’s acquisition of Humana and Anthem’s acquisition of Cigna—will lead to greater efficiencies and innovative payment and care management programs. But is the claim based on fact?

“There is no evidence supporting the insurers’ claim,” the AMA said in a letter (log in) delivered to the U.S. Assistant Attorney General earlier this month. The letter points to studies and analyses that speak to how the opposite is often the case.

The mergers would exceed federal antitrust guidelines put in place to preserve competition around the country. According to special AMA analyses released in September, the proposed mergers of Anthem and Cigna (log in) and of Aetna and Humana (log in) would exceed federal antitrust guidelines designed to preserve competition in as many as 97 metropolitan areas within 17 states. The mergers also would raise significant competitive concerns in additional areas. All told, nearly one-half of all states could see reduced competition in local health insurance markets.

The AMA letter urges the Department of Justice to “block the proposed mergers,” emphasizing that “fostering competition, not consolidation, benefits American consumers through lower prices, better quality and greater choice.”

How would the merger affect physicians and patients?
The proposed mergers would give the merging health insurers monopoly power in the sale of insurance to consumers and create a highly concentrated health insurance market where little competition exists. When no competing options are available, these insurers could raise patients’ premiums and may no longer feel required to develop ways to improve quality and lower costs to compete in a healthy market.

The proposed mergers also can be expected to lead to a reduction in health plan quality. Insurers already are creating very narrow and restricted networks that force patients to go out of network to access care. And in some cases, very restricted networks also may impact patient access and quality by not readily providing a medically appropriate out-of-network benefit to patients or by refusing to count copays to out-of-network physicians toward patient deductibles.

The mergers would reduce pressures on health plans to offer broader networks to compete for members and would create fewer networks that are simultaneously under no competitive pressure to respond to patients’ access needs.

The proposed mergers also would give the insurers monopsony power, or buyer power, over physicians. This would allow the insurers to control physician payment rates, making it impossible for physicians to make practice investments that would improve patient access and care. Without competitive contract terms and rates, physicians may be unable to afford new equipment and technology, struggle to train staff and be forced to spend less time with patients as they work to keep their practices afloat.

In competitive markets, however, consumers are in the driver’s seat. If insurers were to obtain further monopsony power, harm would come to consumers.

“Competition in health insurance, not consolidation, is the right prescription for health insurer markets,” the AMA said. “Competition will lower premiums … [and] allow physicians to bargain for contract terms that touch all aspects of patient care.”

Speaking up
At the 2015 AMA Interim Meeting last week, physicians adopted policy that reaffirmed their commitment to stopping health insurance market consolidation that enhances health insurer market power.

Physicians have been far from silent on this issue. For years the AMA has issued a comprehensive annual study on competition in health insurance markets in the United States. The latest edition was released in early September and included special analyses of the proposed mergers.

The study and analyses were created to help researchers, lawmakers, policymakers and regulators identify markets where mergers and acquisitions among health insurers may harm patients, physicians and employers.

Also in September, members of the AMA Board of Trustees testified in two different congressional hearings:

Continued action
Building on its work with the National Association of Attorneys General, the AMA will present to a majority of state attorneys general later this month. AMA attorneys will  highlight findings from the AMA’s competition study, other analysis of past and pending mergers and emphasize the importance of blocking mergers, such as those between the four major national insurers that are in the works.

The AMA is also continuing its work to  assist state medical associations around the country as they assess how to position themselves regarding the proposed mergers and the actions of their state regulatory agencies.

Back to Top

State Update

Register now for the State Legislative Strategy Conference, Jan. 7-9

Don't miss the opportunity to meet colleagues from across the country, share ideas, talk with experts, learn from nationally renowned speakers, discover policy solutions and develop state legislative agendas that empower physicians to better serve their patients and promote the highest quality in patient care.

The State Legislative Strategy Conference, hosted by the AMA Advocacy Resource Center, is the only meeting in which in the AMA, the American Osteopathic Association and the majority of the state and national medical specialty societies come together to work on the toughest state-level issues in health care today.

Meeting topics this year will include telemedicine, opioids, state-based delivery and payment reform, provider networks, and more. The meeting will begin Jan. 7 at 2 p.m. and conclude Jan. 9 at noon.

For more information, visit the meeting Web page or email Wendy Holmes of the AMA.

Back to Top

Judicial Update

Medical liability reform at risk in state supreme court case

One of the nation’s leading medical liability reform laws could be undercut in a case before a state supreme court. Also tied up in the balance is access to essential medical care for thousands of patients in a highly underserved region of the country.

Montaña v. Frezza a case before the Supreme Court of the State of New Mexico, calls into question whether Texas’ medical liability reforms should apply when New Mexicans seek care from physicians practicing in their neighbor state.

A New Mexico Court of Appeals previously ruled that a New Mexico citizen who travelled voluntarily to Texas to receive elective medical care could file a suit against the physician in New Mexican court and under New Mexican law as a way around its neighbor state’s medical liability reforms.

Sick and injured eastern New Mexico patients rely on Texas physicians for medical care because the region lacks significant and necessary specialties. If Montaña v. Frezza is upheld, opportunities for eastern New Mexico patients to travel to western Texas for medical care will diminish.

The Litigation Center of the AMA and State Medical Societies filed an amicus brief in support of reversing the appeals court’s decision. Montaña v. Frezza places “Texas doctors, nurses and hospitals seeing New Mexico patients at an even greater litigation risk,” the brief said. Increased litigation risk brings with it an increase in the frequency of lawsuit filings and an increase in the size of awards and settlements.

Read more at AMA Wire.

Back to Top

Other News

Medicare participation status changes for 2016

From now until the end of 2015, physicians have an opportunity to change their Medicare participation status for 2016 from “participating” to “nonparticipating.” This is the only opportunity to make this change, and it will be binding for the full year.

Because of the elimination of the sustainable growth rate (SGR) formula, for the first time SGR cuts are not a factor in Medicare participation decisions. Nonetheless, physicians who did not satisfy 2014 Medicare requirements for the electronic health record (EHR) meaningful use program, Physician Quality Reporting System and Value-Based Modifier programs potentially face a 2 percent penalty for each of these programs in 2016.

Collecting the full limiting charge is one way to help offset these penalty programs. Another option for physicians is to opt out of Medicare and privately contract with patients. This change can be made effective at the start of any quarter and is binding for two years. Information on all three options—participation, nonparticipation and private contracting—is available in the updated AMA Medicare Participation Options Kit.

Physicians personalize “Break the Red Tape” photo messages

Physicians at the 2015 AMA Interim Meeting in Atlanta helped communicate a powerful message on burdensome meaningful use regulations that negatively impact electronic health records (EHR). By personalizing a short message and posing for pictures that were instantly shared on Facebook, Twitter and Instagram, physicians were able to express their frustrations and also offer proactive solutions to make the meaningful use program work for their patients and practices.

More than 100 physicians took pictures that will be featured at and shared with members of Congress and officials within the Obama Administration. These pictures reinforce the campaign’s overarching message that lawmakers need to work quickly to hit the reset button on meaningful use.

Latest updates from 2015 AMA Interim Meeting

The 2015 AMA Interim Meeting took place last week. Here are a few of the key stories to know:

Visit AMA Wire to learn more about the meeting.

Back to Top

News You Can Use

Following is suggested content to use in your association’s communication vehicles beginning this month. 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.

Back to Top

Upcoming Events

Nov. 30: Survey to improve EHRs
Want to improve your electronic health records (EHR)? You can help make EHR summary-of-care documents easier to use and more helpful by taking a 5-10 minute survey by the Nov. 30 deadline. Doing so will help the Office of the National Coordinator for Health IT identify the data that physicians typically need in a summary of care so the agency can improve this portion of the meaningful use program.

Dec. 9: Webinar on minimizing prior authorization hassles
Join the AMA for a webinar, “Break through the prior authorization roadblock,” at 1 p.m. Eastern time. Register today to find out how practices can minimize the impact of this major administrative burden.

Feb. 19-21: 2016 AMPAC Candidate Workshop
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.

April 13-17: 2016 AMPAC Campaign School
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.

Back to Top