Sept. 15, 2016
National UpdateMACRA penalties can now be avoided, CMS says
Avoiding penalties under the Medicare Access and CHIP Reauthorization Act (MACRA) just got easier. The Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt today announced that the final MACRA regulation will exempt physicians from any risk of penalties if they choose one of three distinct reporting options in 2017.
In a blog post, Slavitt announced that CMS heard physicians' concerns about the proposed start date for performance reporting under the new Medicare payment system and that the agency will offer three reporting options for the Merit-based Incentive Payment System (MIPS)—and if you choose one for 2017, you will not receive a negative payment adjustment in 2019.
The options will be described fully in the final rule, but here are the basics:
- Option one: Test the program
As long as you submit some data to the Quality Payment Program, including data from after Jan. 1, you will avoid a negative payment adjustment, Slavitt said. This option is intended to ensure that the system is working and that physicians are prepared for broader participation in the coming years as they learn more.
- Option two: Partial-year reporting
Physicians can choose to report Quality Payment Program information for a reduced number of days. Your first performance period could begin well after Jan. 1 and your practice could still qualify for an incentive payment.
Slavitt offered an example. "If you submit information for part of the calendar year for quality measures, how your practice uses technology and what improvement activities your practice is undertaking," he said, "you could qualify for a small positive payment adjustment."
- Option three: Full-year reporting
If your practice is ready to get started on Jan. 1, you can choose to report Quality Payment Program information for the full calendar year. Your first performance period would begin on Jan. 1, and if you submit information for the entire year your practice could qualify for a modest positive payment.
- Advanced Alternative Payment Model (APM) option. This option is still available and qualified participants in advanced APMs will be eligible for five percent incentive payments in 2019.
Choosing any of these three options guarantees that you will not receive a negative payment adjustment.
The announcement confirms that physician input is playing a critical role in the development of the final MACRA rule. Slavitt stated his appreciation for the constructive participation of physicians in the feedback process and added that CMS looks forward to further engagement with physicians to make sure the new Medicare payment system works for everyone, including patients.
"By adopting this thoughtful and flexible approach, the Administration is encouraging a successful transition to the new law by offering physicians options for participating in MACRA," said AMA President Andrew W. Gurman, MD, in a statement commending Slavitt and Department of Health and Human Services Secretary Sylvia Mathews Burwell.
"This approach better reflects the diversity of medical practices throughout the country," he said. "The AMA believes the actions that the Administration announced today will help give physicians a fair shot in the first year of MACRA implementation."
This kind of flexibility is what physicians were seeking throughout the draft rule comment period—and now it is a reality. The only way to receive a negative payment adjustment now is by not participating at all.
The AMA recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the 2017 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule.
A number of the policies in this rule take steps to address issues of longstanding concern to the AMA. Specifically these proposals include:
- CMS' proposal to allow physicians to report Meaningful Use (MU) for 90-days in 2016, instead of a full year. After advocacy from AMA, CMS also proposed a hardship exemption that would allow first time MU participants to report once in 2017 to satisfy both MU and the Advancing Care Information performance category in the Merit-Based Incentive Payment Systems. Read more at AMA Wire®.
- CMS' proposal to eliminate the site of service payment differential between physician offices and off-campus provider-based departments formed after 2017. The AMA supported this proposal, as it may help preserve small, independent practices by eliminating the incentive for hospitals to purchase physician practices.
- CMS' proposal to remove pain measures from the Hospital Value-Based Purchasing Program (VBP).
There are also policies included in the proposed rule that concern the AMA. These include:
- CMS' proposed continuation of long-standing policies that have created and are widening a very large gap between payments in hospital outpatient departments and ambulatory surgical centers.
- CMS' proposal to initiate Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems survey-based measures. The AMA urged CMS to consult with stakeholders to rework the survey and collection requirements for these measures.
- CMS' proposal for further consolidation of Ambulatory Payment Classification groups that appear to be based, at least in part, on inadequate analysis.
As one part of its effort to end the epidemic of opioid overdose deaths, the White House recently invited comments on a number of questions regarding expanding efforts to educate physicians and others who prescribe opioid analgesics.
The AMA's response noted that the professional educational needs of practicing physicians vary by specialty and practice and that better linkages could help physicians identify the educational programs that are most focused on and relevant to their patient populations.
The AMA also suggested that physician actions such as co-prescribing naloxone to prevent overdose deaths, becoming certified to provide medication-assisted treatment with buprenorphine, and taking education to achieve competence in safe opioid prescribing could potentially qualify as Clinical Practice Improvement Activities in the Merit-based Incentive Payment System.
Issue SpotlightMedicare fee schedule proposed rule needs work
The AMA recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) on the agency's proposed rule to revise the Medicare Physician Fee Schedule and Part B. Some of the provisions align with physicians' previous recommendations while others will require some changes, especially those that mean more costs for patients and undercut the Medicare Access and CHIP Reauthorization Act (MACRA).
Three of the proposed policies that the AMA recommended changes to include:
- Requiring physicians to submit data on every 10-minute increment of patient care activities before and after all services covered in a 90- or 10-day global procedure code
- Creating a $44 add-on payment for services provided to patients with mobility-related disabilities, who would then have a $9 co-pay increase
- Changing quality measures used to assess Accountable Care Organization performance
The letter submitted to CMS also detailed several areas where physicians were in agreement with the proposal, including:
- Improved payment for primary care, care management and patient-centered services
- Expansion of the Diabetes Prevention Program
- Addition of new telehealth codes
Read more at AMA Wire.Back to Top
State UpdateAnthem-Cigna deal is bad medicine
In a recent hearing before New York State Department of Financial Services, representatives of the AMA and Medical Society of the State of New York (MSSNY) advised state insurance regulators to reject a deal proposed by Anthem, parent of Empire Blue Cross/Blue Shield, to acquire rival Cigna.
The physician organizations warned that the pending blockbuster merger is bad medicine for New York State that threatens health care access, quality and affordability. Physician representatives warned that the proposed merger amounts to a grab at anticompetitive market power that would quash competition in several of the state's health insurance markets.
Read the full press release and visit the AMA's web page (log in) about the health insurer mergers for additional details. If you would like to request permission to access the website, please email Kai Sternstein of the AMA.
While much more work remains to reverse the nation's opioid epidemic, using tools such as prescription drug monitoring programs (PDMP), medication-assisted treatment and naloxone, physicians are making progress. A new fact sheet provides some evidence of that progress on a number of fronts.
The AMA and many medical and other health care organizations last October joined President Obama in Charleston, W.Va., to commit to clear metrics to reduce the nation's opioid epidemic. The AMA clearly recognizes that more work remains to reduce opioid-related mortality and ensure access to care for patients in pain and who have a substance use disorder.
In a fact sheet released by the AMA, physicians' progress to reverse the nation's opioid epidemic was quantified showing new trends in the use of available tools:
- Nation's opioid supply decreasing. Every state in the nation saw a reduction in opioid prescribing in 2015—an overall 10.6 percent decrease nationally.
- More physicians trained to treat opioid use disorders. From 2012 to 2016 there has been an 81 percent increase in physicians certified to treat substance use disorders—more than 33,000 across all 50 states.
- 15 states showing decreases in total drug overdose deaths. According to the CDC, 15 states saw reductions in the numbers of people dying in 2014 compared to 2013 due to drug overdoses.
- As PDMPs improve, physicians' use increases. AMA research based on responses from more than 40 states found that state-based prescription drug monitoring programs (PDMPs) were checked nearly 85 million times in 2015—a 40 percent increase over 2014. Increases were seen in states with and without mandates to use a PDMP.
- Physicians taking more education. An AMA survey found that nearly 50,000 courses related to opioid prescribing, pain management, or other related areas have been accessed and/or completed by physicians since October 2015. New AMA-created continuing medical education (CME) products will be released soon.
- Naloxone access laws, physician co-prescribing on the rise. In the second quarter of 2015, 4,291 prescriptions were dispensed, a 1,170 percent increase over prescriptions in the fourth quarter of 2013. The AMA encourages physicians to co-prescribe naloxone to patients—or their family members where allowed by state law—at risk of overdose.
For any questions regarding these signs of progress, please contact Daniel Blaney-Koen of the AMA.Ohio proposal to overhaul Medicaid expansion denied
Ohio Medicaid in June submitted a Section 1115 Demonstration waiver proposal to the Centers for Medicare and Medicaid Services (CMS) to redesign the state's Medicaid expansion program. Among other things, the program, called Healthy Ohio, would require all "newly eligible" adult Medicaid enrollees, as well as some low-income parents, foster care youth, and beneficiaries with breast and cervical cancer to pay monthly fees into health savings accounts.
CMS on Sept. 9 denied the state's waiver request citing concerns that the monthly financial obligation would undermine access to coverage and affordability of care. CMS also stated that the plan to exclude individuals indefinitely until debts are paid is inconsistent with the objectives of the Medicaid program.
Ohio estimated that over 125,000 people would likely lose coverage each year for non-payment. If approved, Ohio would have been the first state permitted to disenroll beneficiaries living below the poverty line—$11,880 for an individual—for failing to pay a monthly fee or premium.
For more information on state Medicaid activity, please contact Annalia Michelman of the AMA.
Judicial UpdatePeer-review confidentiality critical, but under threat
Without confidentiality, the peer-review process cannot be an effective tool for improving quality of care. A case before the Supreme Court of Pennsylvania could establish rules that narrow the scope of peer-review protected materials, harming the process.
At stake in Reginelli v. Boggs, is whether the Pennsylvania Peer Review Protection Act (PRPA) privilege against legal discovery should apply when an independent contractor of a hospital reviewed the performance of a physician on the hospital's medical staff.
How the situation unfolded
Eleanor Reginelli presented to the emergency department at Monongahela Valley Hospital (MVH) with chest and back pains. Marcellus Boggs, MD, an emergency medicine physician at MVH, ordered and interpreted the results of an electrocardiogram and blood work. He diagnosed Mrs. Reginelli with gastro-esophageal reflux disease and discharged her that day.
Five days later, Mrs. Reginelli experienced the same symptoms. An ambulance transported her to the emergency department of a different hospital where she was told she was experiencing a heart attack. She subsequently suffered permanent heart damage.
Dr. Boggs was an employee of Emergency Resource Management, Inc. (ERMI), which had been hired as an independent contractor to staff MVH's emergency department. Mrs. Reginelli and her husband sued Dr. Boggs, MVH and ERMI for medical liability.
As part of discovery in the case, the plaintiffs deposed Brenda Walther, MD, the medical director of the MVH emergency department and an ERMI employee. Dr. Walther disclosed that she maintained a performance file on Dr. Boggs, which included peer-review evaluation required by ERMI.
The plaintiffs called on MVH to produce the evaluation file, but MVH objected based on a claim of peer-review privilege in the PRPA. The trial court ordered production of the file, finding that MVH could not claim privilege for a document it had neither generated nor maintained. On appeal, the Pennsylvania Superior Court affirmed and the case is now on appeal before the Pennsylvania Supreme Court.
An agreement for unity in providing quality care
A 2010 "Emergency Department Services Agreement" outlined the relationship and respective duties between MVH and ERMI, noting that the hospital wished to have ERMI provide certain services to facilitate the operation of the emergency department, including the provision of qualified emergency medicine physicians.
The agreement also included materials on quality improvement and peer-review. ERMI was to conduct clinical reviews and provide regular reports to the hospital for its peer-review process. Hospitals commonly use independent contractors to fulfill staffing needs, and those employees then become members of the hospital staff as well as the contractor.
"Peer review is an important tool in improving the quality of health care," said the Litigation Center of the AMA and State Medical Societies in an amicus brief defending the PRPA. "The willingness to criticize peers that an effective review process requires cannot occur without ironclad confidentiality."
"Here, the medical director of a hospital emergency department reviewed treatment records of a department physician," the brief said. "That is the paradigm for protected activity under the Peer Review Protection Act."
Read more at AMA Wire.
Other NewsICD-10 grace period to expire Oct. 1
The Centers for Medicare & Medicaid Services (CMS) announced that the ICD-10 grace period, which began in October of last year, will expire on Oct. 1. The grace period was the result of AMA efforts to work with CMS to help ease physicians' transition from ICD-9 to ICD-10.
During the grace period, Medicare claims were not denied solely on the specificity of the ICD-10 diagnosis code, as long as the physician submitted an ICD-10 code from an appropriate family of codes. In addition, during the grace period Medicare claims were not audited based on the specificity of diagnosis codes if the code was from the appropriate family.
The AMA will monitor the transition and apprise CMS of any issues that emerge as a result of the ICD-10 grace period ending. For additional resources, visit CMS' ICD-10 webpage or AMA's ICD-10 resources.