Sept. 29, 2016

National Update

Reports show 2017 Medicare payment adjustments

Medicare has made available two new reports with information on 2015 cost and quality data that indicate which physicians or practices will see related Medicare payment adjustments in 2017.

The 2015 Physician Quality Reporting System (PQRS) Feedback Reports and 2015 Annual Quality and Resource Use Reports (QRUR) were released on Sept. 26. The Centers for Medicare & Medicaid Services (CMS) is mailing 2015 PQRS penalty letters to physicians beginning Sept. 26.

2015 PQRS penalty letters notify physicians and groups who are scheduled to receive a two percent penalty in 2017 based on 2015 PQRS reporting. The PQRS feedback report allows physicians to look up whether they will receive the two percent 2017 PQRS penalty, and contains detailed information on program year 2015 PQRS reporting results. 

The 2015 Annual QRURs provide information on how practices performed on quality and cost measures used in the Value Modifier (VM) and whether their VM payment adjustment will be positive, negative or neutral and the specific amount. VM penalties can range from -1 to -4 depending on practice size and performance. Bonus payments depend on how much money is collected from penalties and to date the 2017 bonus size has not been publically announced by CMS. Drill-down tables in the reports contain detailed information on care delivered to individual patients by other providers as well as the physicians in the practice.

The payment adjustments detailed in these reports are associated with current performance-based Medicare payment incentives that will be replaced in 2019 with a new system created under the Medicare Access and CHIP Reauthorization Act (MACRA). Practices that believe there are errors in the report or calculation of the payment adjustment should file for an informal review prior to midnight Eastern Time on Nov. 30.

How to access the reports:

Information on the informal review process:

CMS Help Desk information:

ICD-10 update complicates PQRS reporting and value modifier adjustments

The yearly update to ICD-10 coding on Oct. 1 will affect Physician Quality Reporting System (PQRS) reporting for some measures. The update is larger than the traditional yearly ICD update due to a several year freeze on new codes as the healthcare system transitioned from ICD-9 to ICD-10.

Many of the codes involved were not finalized until August 2016 and PQRS measure specifications were not updated to include the coding changes. As a consequence, some codes that are part of the PQRS measures and are necessary to report use of the measure will no longer be included, which may lead to confusion for correct reporting.

PQRS data is also used to calculate Value Modifier adjustments, which means these adjustments might also be affected. Since learning about the issue, the AMA has been working diligently with the Centers for Medicare & Medicaid Services (CMS) toward a resolution. Although CMS is still in the process of developing a solution, the agency has assured the AMA that every effort will be made to prevent physicians from being penalized for issues resulting from the ICD-10 coding update.

We encourage physicians and specialty societies to review the list of affected measures to determine whether the update will affect your specialty area. We will continue to work with CMS on this issue and will update the Federation as we have additional information.  

EHR contract guide and Health IT Playbook released

The U.S. Department of Health and Human Services’ (HHS) Office of the National Coordinator for Health Information Technology (ONC) has released two tools to help physicians maximize their electronic health records (EHR).

The new EHR contract guide, “EHR Contracts Untangled: Selecting Wisely, Negotiating Terms, and Understanding the Fine Print,” explains important concepts in EHR contracts and includes example contract language to help physicians and health administrators in planning to acquire an EHR system and negotiating contract terms with vendors.

The AMA has provided specific feedback to the ONC on EHR vendor contracts related to interoperability limitations, costs and the need for further clarity on EHR capabilities and functionality.

The Health IT Playbook is a web-based tool intended to make it easy for physicians and their practice administrators to find practical information and guidance on specific topics as they research, buy, use or switch EHRs. The Playbook features a collection of specific tools, resources and guides that can help physicians implement and use health information technology that best serves their practices—including supporting transitions toward alternative payment models. The AMA continues to urge HHS to reduce the EHR reporting burden on physicians.

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Issue Spotlight

New analyses support blocking pending insurance mergers

Two analyses demonstrate further that the proposed Anthem-Cigna and Aetna-Humana health insurance mergers would exceed federal antitrust guidelines designed to preserve competition and jeopardize patient access to affordable coverage and care.

The analyses are based on data from the 15th edition of Competition in Insurance: A Comprehensive Study of U.S. Markets, published today by the AMA, which continues to find the majority of commercial health insurance markets in the United States are highly concentrated.

High market concentration can lead to enhanced market power by health insurers on physicians and patients, wherein payments to physicians are lower than those resulting in a competitive market and premiums charged to patients are higher with no added benefits.

The most complete picture of competition in health insurance
Using 2014 data from captured from commercial enrollment in fully and self-insured plans, Competition in Insurance presents the two largest insurers’ commercial market shares and the market concentrations for 388 metropolitan statistical areas (MSAs), the 50 states and the District of Columbia.

“This is the most complete picture available of competition in health insurance markets,” the report said.

In terms of market concentration, it shows:

In terms of market shares, it found:

Pending mergers would cause harm across numerous markets
In 2015, Anthem announced its intent to acquire Cigna, and Aetna announced plans to acquire Humana. All are among the five largest commercial health insurers in the country.

The motivation for Competition in Insurance has been to help identify markets where mergers would cause competitive harm. The analyses of those mergers using data from this year’s report calculated the changes in market concentration that would result from the mergers and then classified markets based on how anticompetitive the mergers would be.

They found:

“The AMA analyses show that the Anthem-Cigna and Aetna-Humana mergers would significantly compromise market competition in the health insurance industry and threaten health care access, quality and affordability,” said AMA President Andrew W. Gurman, MD. “With existing competition in health insurance markets already at alarmingly low levels, federal and state antitrust officials have powerful reasons to block harmful mergers and foster a more competitive marketplace that will operate in patients' best interests."

The AMA and state medical societies have worked behind the scenes in opposition to the two mergers. The AMA has encouraged the Department of Justice (DOJ) and a number of state attorneys general to oppose both on antitrust grounds.

The AMA believes more can be done in states where state regulators have not yet taken a strong stance against the mergers, and it will work to expand the bi-partisan group of state attorneys general that has already joined the DOJ to block the massive deals.

Competition in Insurance: A Comprehensive Study of U.S. Markets is free to AMA members. It is also available to non-members. To order a copy, visit the AMA store or call (800) 621-8335 and mention OP number 427116.

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State Update

New data shows complexity of opioid epidemic

Three new reports may be useful to states as they work to help reverse the nation’s opioid epidemic, and highlight progress so far.

Growth in the use of buprenorphine to treat opioid use disorders has slowed over the past five years and varies widely by state, according to a new study from the IMS Institute for Healthcare Informatics. Claims for opioid use disorder, however, have increased more than 3,200 percent, according to FAIR Health, with claims varying greatly by age.

A research letter in the Journal of the American Medical Association found there is a large, untapped physician capacity to treat patients with an opioid use disorder. Newly compiled data shows multiple signs of progress, including that physicians’ use of prescription drug monitoring programs has increased nearly 40 percent from 2014 to 2015, while opioid prescriptions have decreased by nearly 11 percent in the same period.

For more information about how to use this information in your state efforts, please contact Daniel Blaney-Koen of the AMA. 

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Judicial Update

Court overturns physical therapy decision

A positive decision for patients Thursday was made in the South Carolina Supreme Court to allow physician practices to employ physical therapists, ending a longstanding disagreement regarding how the practice of physical therapy should be regulated in the state.

At stake in Joseph v. South Carolina Department of Labor, was whether physical therapists in South Carolina can provide treatment as direct employees of physicians to make that service more easily available for patients. The ruling: Physicians in South Carolina can now employ physical therapists in their practice.

“This patient-centered decision from the Court supports our contention that integrated physical therapy services can be in the best interest of patients when handled ethically and in compliance with existing self-referral restrictions,” the South Carolina Orthopaedic Association said in a statement.

What led to the overturn
The South Carolina Board of Physical Therapy has long sought to require physical therapists to provide their services directly to patients or through a practice group of physical therapists. However, other licensed health care professionals such as occupational therapists, speech pathologists and nurse practitioners may be employed by physicians in the state.

In 2006, the South Carolina Supreme Court ruled in Sloan v. South Carolina Board of Physical Therapy that the state’s Physical Therapy Practice Act prohibited physical therapists from working in a physician’s office and providing physical therapy to the physician’s patients through what are referred to as “in-practice referrals.”

The decision caused many problems for patients, physicians and physical therapists, changing the way physical therapy was practiced in South Carolina and making it more difficult for patients to access physical therapy services. That decision was overruled Thursday, allowing physical therapists to work directly with physicians to provide their services to patients.

“In Sloan, this Court interpreted … the South Carolina Code as prohibiting a physical therapist from being employed by a physician when the physician refers patients to the physical therapist for services,” the Court said in the decision. “Contrary to that decision, we now find that the classification, which distinguishes physical therapists from other licensed health care professionals, has no rational relationship to the legislative purpose of the statute.”

The Litigation Center of the AMA and State Medical Societies and the South Carolina Medical Association jointly supported the plaintiffs, who were a physical therapist and two orthopedic surgeons. The now overruled Sloan decision had unnecessarily burdened patients’ access to health care services—an obstruction which the Litigation Center has worked hard to overcome.

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Other News

Provide your input on real-time pharmacy benefit transactions

Over the past two years, the AMA has been working with the National Council for Prescription Drug Programs (NCPDP) and other industry leaders to develop a Real-Time Prescription Benefit Inquiry (RTPBI) transaction.

The AMA has strongly advocated for an RTPBI process that will allow physicians to obtain real-time information about a patient’s prescription benefits for a specific drug—including formulary status, coverage restrictions, pharmacy network and patient co-pays—at the point of care. Such information can help support informed physician-patient discussions and decisions about medication therapy.

NCPDP has scheduled two webinars to solicit feedback on various prescribing scenarios that would involve the RTPBI. The AMA encourages interested Federation staff and physicians to attend the webinars and provide feedback to ensure that the future transaction provides useful information that will help prescribers discuss medication choices with their patients and efficiently address any formulary or coverage restrictions at the time of prescribing. The webinars are scheduled for the following dates/times:

For more information and to register, please visit the NCPDP website.

MACRA update

As we await the release of the Centers for Medicare & Medicaid Services (CMS) final rule on the Medicare Access and CHIP Reauthorization Act (MACRA), we want to update you on our latest advocacy work and new physician resources. Through the MACRA Task Force and various work groups, the AMA and the Federation have been collaborating to develop strategic approaches to our advocacy, along with consistent messaging.

The AMA recently filed extensive comments on CMS’ proposed rule, emphasizing the need for greater flexibility and choice.

We saw further evidence that CMS has been listening to physician concerns, when CMS Acting Administrator Andy Slavitt announced that physicians can choose among four options to avoid payment penalties in 2019. Medicine welcomed CMS’ decision to allow physicians to pick their own pace for the initial MACRA reporting period in 2017 as a positive step toward giving all physicians a fair opportunity to succeed.

Although details on MACRA implementation will not be available until the final rule is released later this fall, we have developed a number of resources to help physician practices begin to prepare for the transition to the new payment system:

There is much more to come this fall as we release our new web-based tool to help physicians understand which MACRA pathway is best for them and assess its impact on their practice, and we develop new resources after the final rule is released. We are also planning regional seminars on MACRA, as well as webinars for physicians and “train the trainer” webinars for medical society staff.

Register for Advocacy Update and AMA Morning Rounds to stay up to date with news about MACRA and new resources. 

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