Aug. 4, 2016
National UpdateRegister for Aug. 10 webinar on the Zika virus outbreak
The AMA is cohosting a one-hour webinar on Aug. 10 at 7 p.m. Eastern time with the Centers for Disease Control and Prevention (CDC) to update clinicians on the current state of the Zika virus outbreak and the latest clinical guidance. Webinar participants will hear from two experts from the CDC who will offer valuable information to help health care professionals diagnose and manage patients with possible Zika virus infection and explain the latest clinical guidance on preventing transmission:
- Susan Hills, MBBS, CDC medical epidemiologist, will present an update on the epidemiological and clinical aspects of the current outbreak.
- Kiran Perkins, MD, CDC medical officer, will discuss the implications for pregnant women, including the CDC's updated interim clinical guidance.
The presentations will be followed by a question and answer session. The webinar will take place during the U.S. Department of Health and Human Services' health provider "Week of Action" on Zika virus.
Register to participate in the webinar.
CMS has opened the application process until Sept. 15 for practices to apply for Comprehensive Primary Care Plus (CPC+). In CPC+, CMS has provisionally selected 57 payer partners, including commercial insurers, state Medicaid agencies, Medicaid managed care organizations and Medicare Advantage plans in 14 regions across the nation.
Up to 5,000 practices will be selected to participate, and CPC+ participants will be eligible for the alternative payment model bonus payments available under MACRA starting in 2019. Click on the map below to read about the 14 CPC+ regions and provisionally selected payers.
For more information on CPC+:
- Get your questions answered in the Practice FAQs
- Register for one of the 20 upcoming CPC+ Practice Open Door Forums in August and September
- Watch the CPC+ Video Series to get an overview of CPC+ payment innovations and care delivery transformation
- Submit a CPC+ application via the online portal today through 11:59 p.m. Eastern time on Thursday, Sept. 15
- Download the CPC+ toolkit: CPC+ In Brief, CPC+ Care Delivery Transformation Brief, and CPC+ Payment Innovations Brief and Case Studies
Thanks to the efforts of the Oklahoma State Medical Association (OSMA) and other state leaders, Oklahoma has seen the second largest decrease among states in opioid prescriptions from 2013-2015—down nearly 18 percent. From 2013 to 2014, Oklahoma was one of the 15 states that saw a decrease in mortality due to drug overdose.
In an op-ed published in the Tulsa World, AMA Chair Patrice A. Harris, MD, and OSMA President Sherri Baker, MD, noted that these results are signs of progress, but more work is needed to reverse the epidemic, including an increased emphasis on treatment.
"We must continue to work toward the day when all Oklahomans with a substance use disorder are in treatment; when all Oklahomans with chronic pain have access to comprehensive, evidence-based treatment," said Drs. Harris and Baker.
Last week, the AMA submitted a sign-on letter on behalf of 98 specialty and state medical societies urging the Veterans Health Administration (VA) not to move forward with its Advanced Practice Registered Nurses (APRN) Proposed Rule. If finalized, all VA-employed APRNs would be permitted to practice independently without the clinical supervision of physicians and without regard to state law.
Efforts at the VA to permit independent nursing practice go back several years but gained momentum when significant staffing shortages and long patient wait times were uncovered in 2014.
The 98 signatories to the letter strongly opposed the proposed rule and advised the VA to consider policy alternatives that prioritize physician-led team-based care rather than independent nursing practice.
The requirements of a nondiscrimination rule issued by the U.S. Department of Health and Human Services Office of Civil Rights (OCR) on May 13 became effective on July 18. The rule implements section 1557 of the Affordable Care Act (ACA), which makes it unlawful for any health care provider who receives funding from the federal government to refuse to treat an individual—or to otherwise discriminate against the individual—based on race, color, national origin, sex, age or disability.
The rule does not apply to physicians who participate only in Medicare Part B, though it does apply to physicians who participate in Medicaid or receive meaningful use incentive payments. Physicians should note that in addition to administrative enforcement mechanisms, such as loss of federal financial assistance, individuals are permitted to bring individual or class action violation claims directly against them in federal court.
Covered physicians must comply with the following requirements:
- Submit an assurance of compliance form to OCR
- Post a notice of nondiscrimination and taglines in multiple languages
- Develop and implement a language access plan
- Designate a compliance coordinator and adopt grievance procedures (applicable to group practices with 15 or more employees)
To help reduce burden and costs, OCR has translated into 64 languages a sample notice and taglines for use by covered entities. In addition, OCR has published a summary of the rule, factsheets on key provisions and a list of frequently asked questions.
Issue SpotlightNew model makes patient care more than face-to-face visits
Two things that physicians want for their patients are more stability and fewer visits to the emergency department. But often the services that are needed to do so are unbillable, and the resources are hard to find otherwise. A new care model for oncologists intends to solve this problem by providing the resources needed to closely manage patients' care in-between their face-to-face treatments to reduce complications.
The American Society of Clinical Oncology (ASCO) developed the patient-centered oncology payment model, an alternative payment model (APM) that focuses on two things: making sure the patient is taken care of in a way that prevents complications, which helps them progress toward improved overall health, and ensuring physicians have the necessary resources to provide that quality care.
"The current system is flawed in many ways because it doesn't pay for the services and the support that patients need and want," said Robin Zon, MD, an oncologist and member of the ASCO's Oncology Payment Reform and Implementation Workgroups. "But physicians are paying for it in a number of other ways in order to be able to deliver those services to the patient."
"What's happened over time," she said, "is that practices aren't able to accommodate those expenses to be able to optimally care of the patient. There are services that the patient is receiving and needs, but they're non-reimbursable services."
How the model works
"We developed a system that does three major things," Dr. Zon said. The model shifts the focus away from typical fee-for-service, holds physicians accountable for high-quality care and makes physicians accountable for only those services they are able to control.
So how does the payment model work, and what kind of difference will it make? Dr. Zon gave an example of a patient we will call John:
- Before the new model
Three years ago, before the patient-centered oncology payment model, John would go into a small practice for his chemotherapy. Then he would head home afterwards with instructions to call the office with any concerns or questions. The next day he didn't feel very good. But he didn't want to bother the doctor, thinking it was a normal reaction to the chemotherapy or the underlying cancer, so he didn't call the office. Since this is a small office, there is no extra staff to conduct outbound triage to check on John. Two days later he had severe diarrhea and nausea and ended up so dehydrated that he had to go to the emergency department.
- After the new model
Now, John goes into a practice that has implemented the patient-centered oncology model. The next day, an outbound triage nurse calls him at home and asks how he is doing. John says he's not feeling too great. The nurse says, "Let me talk to the doctor and get back to you." The nurse calls John again with recommendations from the doctor based on how he is feeling and reeducates him on how to use his supportive care medications.
The nurse calls again the next day to see if John is feeling any better. John says he's feeling a little better but not perfect. The nurse responds, "Let me talk to the doctor again." The next phone call to John includes some adjustments in hydration and diet, as well as recommendations on how to use the supportive medications. In the end, they're able to help John get through those initial three days, and he never ends up at the hospital.
"The exciting thing about this model is that the focus really is on the patient, which is why I like the name of the model so much," she said. "It's patient-centered, meaning the [payment] supports the resources needed to provide the care the patient needs and wants. This is opposed to the current system of [paying] only for face-to-face visits, which does not care for the patient between these encounters."
Three payment options in the model
"Our philosophy, from the ASCO perspective," she said, "is that really what we should be designing is a [payment] system that supports the services that patients need and deserve and want," not just those that are provided when the patient comes into the practice for a visit or chemotherapy.
ASCO designed a system that has three payment options for oncologists:
- Care management payments. This approach takes the existing E/M codes and adds care management codes during an episode of care. An episode of care is defined as a period of time that a patient receives chemotherapy, approximately six months.
Calculating the total cost for time and resources was the next step. Currently, when physicians see a new patient they are paid X by an E/M code. The amount of time and resources spent in the new patient evaluation and treatment planning is really X plus Y, which is the care management component. But physicians are only paid for X.
The care management payment would also persist during active treatment and would "help pay for things like outbound triage nurses that check on patients," Dr. Zon said. "After the active payment period, there would be a short period of continued care management because there is management of the after effects of treatment that do require resources from the office, and [they don't] require a face to face visit."
"Right now, we only get paid for face to face encounters," she said, "but we do so much more for patients that is beyond face to face and not billable."
- Monthly payments. In this option, there are monthly fees for treatment design and then for active treatment and follow up. The intention is to better support the array of services that are needed when a patient is first diagnosed with cancer and to allow more flexibility in how care is delivered to the patient. The monthly fee would replace the E/M codes with monthly payment codes.
This option would significantly reduce the number of codes required for billing. The doctor is then responsible for allocating the resources in a manner that supports the services required for the patient's care.
- Bundled payment. A bundled payment is paid to the physician. It includes not only the oncology practice costs but also other costs such as tests, hospitalizations and possibly drugs.
It is yet to be decided if the bundled payment will be paid ahead of time or after delivery of services.
"It's important to stress in all three of the options there is a transitioning away from fee-for-service to what we are calling value-based patient-centered care which includes accountability," Dr. Zon said. "In fact, the model includes providers being measured with regards to delivery of quality care, but only for the services that oncologists can control."
The big difference between this APM and the Center for Medicare and Medicaid Innovation's Oncology Care Model is that physicians are only held accountable for the areas they can control, she said. For example, "if the patient has a cardiac event under our APM … that would not be included in our requirements to attest to delivering quality care because we can't control what the cardiologist thinks is necessary for that patient."
"Other demonstration projects have actually have shown … that just by providing the money for care management as well as non-face-to-face, non-reimbursable services," she said, "that you're able to reduce … some of the biggest cost [drivers] in health care, which is acute hospitalizations."
ASCO is currently testing the model in several pilot programs and plans to present this model to the Physician-Focused Payment Model Technical Advisory Committee (PTAC)—a committee of experts who will advise CMS on APMs for the new Medicare payment system.
Watch for a podcast interview from ReachMD in the coming weeks with Dr. Zon.
Listen to a podcast interview with Lawrence Kosinski, MD, who discusses his APM, SonarMD. Also, learn about Dr. Kosinski's APM at AMA Wire®.
State Update"Connecting the Dots"—new pilot project to increase MAT in 14 states
A new pilot program, "Connecting the Dots," aims to increase awareness and promote the need for evidence based approaches to clinical practice in the use of medication assisted treatment (MAT) in 14 states.
The program was launched in partnership by the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration, with the American Academy of Addiction Psychiatry (AAAP) and their partner organizations American Psychiatric Association, American Osteopathic Academy of Addiction Medicine, and American Society of Addiction Medicine with the Association for Medical Education and Research.
PCSS-MAT organizations are members of the AMA Task Force to Reduce Opioid Abuse, and are seeking state medical societies interested in forming a collaborative relationship to help provide educational resources, training and a mentoring program for health professionals in the prevention, identification and treatment of opioid use disorder—as well as other substance use disorders and co-occurring mental disorders. All resources in the program are available at no cost, and most offer CME at no cost as well.
The fourteen states in this pilot project include Kentucky, Mississippi, Missouri, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Oklahoma, Pennsylvania, Tennessee, Utah, Virginia, and West Virginia.
Medical societies not already involved in one of these state-based coalitions are encouraged to contact Kathryn Cates-Wessel at email@example.com.
Judicial UpdateBanning expert testimony from liability cases: Court decides
Can trial courts block physicians' expert witnesses from testifying in medical liability cases? One Wisconsin court recently did, leaving it to the court of appeals to decide whether a physician defendant has the right to present expert testimony that differs from that of the plaintiffs.
At stake in Bayer v. Dobbins was whether trial court had properly excluded expert testimony regarding injuries to a newborn that had resulted in complications in the birthing process.
What happened in Wisconsin
Leah Bayer was delivering her child under the care of Brian D. Dobbins, MD, when the progress of the delivery slowed and she began to show signs of exhaustion. Dr. Dobbins made the decision to use a vacuum to advance the child down the birth canal.
The child's shoulder became stuck inside the canal, causing shoulder dystocia, a condition in which the fetal shoulder becomes lodged on the maternal pelvis. A shoulder dystocia is considered an emergency because it can lead to compression of the umbilical cord, which can compromise blood flow and oxygen supply to the child.
After using two "traction" maneuvers, Dr. Dobbins was able to successfully deliver the child. But the child had reduced movement of her right arm and was ultimately diagnosed with a permanent right brachial plexus injury—which severely limited her ability to use her right arm and hand.
The Bayers sued Dr. Dobbins, claiming that he had used excessive traction during the delivery. Dr. Dobbins contended that he had appropriately used only gentle downward traction to deliver the child and that the injury was caused by maternal forces of labor, including the forces associated with contractions and pushing.
In support of Dr. Dobbins' medical care, the defense tendered as expert witnesses four well-known medical scientists whose testimony was supported by dozens of peer-reviewed medical studies. Many of the studies had been published by or were connected with the American College of Obstetricians and Gynecologists (ACOG). One of the studies Dr. Dobbins proffered as evidence concluded that the condition "has been shown to occur entirely unrelated to traction …." The study was published by ACOG in 2014.
Before the trial began, the Bayers filed a motion asking the circuit court to exclude all expert testimony relating to Dobbins' theory that maternal forces of labor caused the injury, arguing that the experts' opinions were unreliable because the Bayers' biochemical engineering expert had disproved the maternal forces theory in 2007 using a simulator.
The trial court ultimately ruled in favor of the Bayers and excluded the defendant's expert witnesses. It also determined that the medical literature was "inappropriate" because it did not adequately differentiate between permanent and temporary brachial plexus injuries.
On appeal, court reverses decision
A Wisconsin Court of Appeals granted Dr. Dobbins' appeal of the order that prevented his expert witnesses from testifying.
Citing the ACOG study, the Litigation Center of the AMA and State Medical Societies and the Wisconsin Medical Society said in an amicus brief, "This resource, which Dr. Dobbins' experts used to support their opinions, is an example of a systematic review of observational studies. … publications like this represent some of the best evidence available to physicians in medical decision making."
"This court has the opportunity with this case to provide significant guidance to Wisconsin's trial courts," the brief said. "The society can envision no more logical source of determining the reliability of such evidence than medicine's own standards of reliability."
Last week, the Wisconsin Court of Appeals ruled that, because competing scientific theories were presented, it was for the jury to decide which of the theories best fit the facts of the case.
"If experts are in disagreement," the court said in the decision, "it is not for the court to decide 'which of the several competing scientific theories has the best provenance.'"
As a result of the decision, Dr. Dobbins' expert witnesses and the medical literature supporting their testimony will be allowed in the case.
Other NewsPrepare CMS reports review—create or update your EIDM accounts
The Centers for Medicare & Medicaid Services (CMS) will be releasing two reports in early fall that will require an Enterprise Identity Management (EIDM) account to access. Practices or individual physicians will also need an EIDM account if they need to file an informal review of contested 2015 Physician Quality Reporting System (PQRS) and Value Modifier (VM) data and results.
The reports scheduled for release are:
- PQRS feedback reports depicting your program year 2015 PQRS reporting results, including payment adjustment assessment for 2017
- 2015 Annual Quality and Resource Use Reports (QRURs) that will show how groups and solo practitioners performed in 2015 on the quality and cost measures used to calculate the 2017 Value Modifier
Prepare now either by signing up for an Enterprise Identity Management (EIDM) account or ensuring that your existing account is active and updated. The same EIDM account can be used to access both reports or file an informal review. To register for an EIDM account, visit the CMS Enterprise Portal and click "New User Registration" under "Login to CMS Secure Portal."
For assistance with registering or updating your information, please review the CMS EIDM System Toolkit. The CMS resources provide instructions for PQRS participants on obtaining a new EIDM account, managing and updating information for an existing EIDM account and adding account role(s) in the Physician Value-Physician Quality Reporting System (PV-PQRS) Domain.
For additional assistance regarding EIDM, contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715- 6222) from 7 a.m. to 7 p.m. Central time, Monday through Friday, or via email at firstname.lastname@example.org.