April 20, 2017

Issue Spotlight

Time is short for critical action to stabilize individual market

Vital funding that reduces the costs borne by 7 million Americans who purchase coverage through the health insurance exchanges will soon be endangered if Congress and the Trump administration do not act quickly to ensure it continues to be available to the low- and moderate-income patients who need it.

There is great uncertainty surrounding these cost-sharing reductions, which 60 percent of individuals who buy coverage through the health insurance exchanges rely upon to help with deductibles, co-payments or out-of-pocket limits. The payments are the subject of a lawsuit filed by members of Congress in 2014 and still pending in the federal courts.

Resolving doubts about the continued funding of the cost-sharing reductions is "the most critical action" that could be taken "to help stabilize the individual market for 2017 and 2018," says a letter sent to the Trump administration and Congressional leaders by the AMA and seven other organizations representing family physicians, hospitals, businesses, employers and health insurers.

The funding covers consumers who earn less than 250 percent of the federal poverty level, and "Americans will be dramatically impacted" if cost-sharing reductions end, the letter says. The likely outcomes include fewer choices for health insurance consumers and higher premiums in 2018 and beyond. Analysts have estimated that the loss of cost-sharing reductions would raise premiums for all consumers in the individual market  by at least 15 percent, regardless of whether they buy coverage through the exchange marketplace.

"Higher premium rates could drive out of the market those middle-income individuals who are not eligible for tax credits," says the letter, signed by the AMA, American Academy of Family Physicians, American Hospital Association, Federation of American Hospitals, American Benefits Council, U.S. Chamber of Commerce, America's Health Insurance Plans, and the Blue Cross Blue Shield Association.

If the funding ends and more Americans go without coverage, hospitals, clinics, physicians and other health professionals are likely to see more of their care go uncompensated. That "will further strain their ability to meet the needs of their communities and will raise costs for everyone, including employers who sponsor group health plans for their employees," the letter says.

"We are committed to working with you to deliver the short-term stability we all want and the affordable coverage and high-quality care that every American deserves," the letter says. "But time is short and action is needed."

Read more at AMA Wire®.

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National Update

Physician-focused payment models recommended to Secretary Price

In April, the Physician-Focused Payment Models Technical Advisory Committee (PTAC) had its first meeting to review and vote on proposals it has received. Following an in-depth review and discussion with the physician leaders who had submitted the proposals, the PTAC voted to recommend two proposals to Health and Human Services Secretary Tom Price, MD, for limited testing. 

The first, called Project Sonar, has been spearheaded by Lawrence Kosinski, MD, an Illinois gastroenterologist. With support from a private payer, it has demonstrated significant improvements in care for patients with inflammatory bowel disease (IBD). Project Sonar engages these patients in an interactive process that allows the gastroenterology team to take steps to reduce exacerbations that would otherwise lead to emergency visits and hospital admissions. 

The second model recommended by PTAC for testing is the Episode Grouper for Medicare (EGM) developed by the American College of Surgeons and Brandeis University. The EGM model will provide data to teams of physicians managing episodes of care that can help them to improve quality and outcomes of care and lower avoidable spending. 

Both models hold promise for improving patient care as well as providing a means for specialist physicians who have had few opportunities to participate in alternative payment models to effectively do so. In remarks at the PTAC meeting, Secretary Price strongly encouraged the physician community to submit additional proposals for new models to the PTAC. He emphasized the need to avoid a one-size-fits-all approach and noted that we are in a time of great innovation in clinical medicine that requires innovation in payment models as well.

Learn more about both of these models at AMA Wire, and listen to a podcast interview with Dr. Kosinski about Project Sonar. The AMA website offers additional details on APMs and how to develop APMs.

CMS releases 2018 Hospital Inpatient Prospective Payment System (IPPS) proposed rule

On April 14, 2017, the Centers for Medicare and Medicaid Services (CMS) released the 2018 Hospital IPPS and LTCH Prospective Payment System proposed rule and a fact sheet on the proposed rule. The proposed rule would update payments to acute care hospitals that report quality data and Meaningful Use by 1.6 percent in 2018. 

In the rule, CMS proposes to update the Hospital Inpatient Quality Reporting (IQR) Program by making several changes, including updating the Hospital Consumer Assessment of Healthcare Providers and Systems Survey measures by replacing the previous questions about Pain Management with three new questions that address "communication about pain during the hospital stay." In addition, CMS proposes to change the risk-adjustment methodology used in the hospital 30-day, all-cause, risk-standardized mortality rate following acute ischemic stroke hospitalization (Stroke 30-Day Mortality Rate) measure to include stroke severity codes (based on the NIH Stroke Scale), beginning with the fiscal year 2023 payment determination.

CMS also proposes adjustments to the Hospital Value-Based Purchasing (VBM) program, including removing one measure, PSI 90: Patient Safety for Selected Indicators, in 2019. CMS proposes to adopt one new measure, Hospital-Level, Risk-Standardization Payment Associated with a 30-Day Episode of Care for Pneumonia, in 2022, and adopt a second new measure, Patient Safety and Adverse Events Composite (NQF No. 0531), beginning in 2023. CMS also asks for comments on the appropriateness of accounting for social risk factors in both the Hospital VBM program and the Hospital IQR program, and feedback on which social risk factors should be included.

For the Medicare and Medicaid Meaningful Use (MU) programs, CMS is proposing to reduce the 2018 electronic health record (EHR) reporting period from a full year to 90 days. Note that in this rule CMS is not proposing changes to the advancing care information (ACI) reporting period in the Merit-based Incentive Payment System program, which will be dealt with in a separate rulemaking. CMS also proposes to add a new exception for the MU program for participants who cannot meet the MU requirements because their certified electronic health record technology has been decertified. CMS is also proposing changes to the clinical quality measures (CQMs) to better align them with other quality reporting programs. 

In addition, the proposed rule includes two requests for information (RFI). The first RFI seeks public input on the appropriate role of physician-owned hospitals in the delivery system and how the current scope of and restrictions on physician-owned hospitals affect health care delivery. The second RFI asks for feedback on CMS flexibilities and efficiencies, including regulatory, subregulatory, policy, practice and procedural changes that could be made to improve the health care delivery system and reduce unnecessary burdens for physicians and patients. 

The American Medical Association will continue to review CMS' proposals and provide detailed comments on the proposed rule.    

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State Update

Interstate Medical Licensure Compact launched

At long last, the Interstate Medical Licensure Compact is live. Physicians in Compact states can apply for expedited licenses.

Currently, seven of the 18 states in the Compact are ready to issue licenses through the Compact. These are Alabama, Iowa, Idaho, Kansas, West Virginia, Wisconsin and Wyoming. The remaining 11 states—Arizona, Colorado, Illinois, Minnesota, Mississippi, Montana, New Hampshire, Nevada, Pennsylvania, South Dakota and Utah—are still preparing to accept applications for verification and a background check. This issue should be resolved shortly. 

The AMA strongly supports the Compact and is interested in working with any state medical association that wishes to pursue Compact legislation in your state. Eight states—Maine, Michigan, North Dakota, Nebraska, Rhode Island, Tennessee, Texas and Washington—and the District of Columbia have Compact legislation pending. Contact Kristin Schleiter with any questions or for additional resources on the Compact.

Kentucky enacts medical review panel legislation

In March, Kentucky Gov. Matt Bevin signed Senate Bill 4, an act to establish medical review panels to review proposed malpractice complaints against physicians and other health care providers. Under Kentucky's new law, all malpractice and malpractice-related claims against a health care provider, other than those previously agreed to be submitted to arbitration, will be reviewed by a medical review panel composed of one attorney and three health care providers. An action cannot be commenced in court before the complaint has been presented to the medical review panel, and within nine months, an opinion has been given by the panel.

At the end of the review process, the panel will issue a written opinion stating whether: (a) the evidence supports the conclusion that the defendant failed to comply with the standard of care and the conduct was a substantial factor in producing a negative outcome for the patient; (b) the evidence supports the conclusion that the defendant failed to comply with the standard of care, but the conduct was not a substantial factor in producing the negative outcome; or (c) the evidence does not support the conclusion that the defendant failed to meet the standard of care. If the case proceeds to trial, this opinion, while not considered conclusive, can be admitted into evidence as an expert opinion subject to cross-examination. See the text of Senate Bill 4 for more details.

The AMA is proud to have supported the Kentucky Medical Association's (KMA) multiyear effort to enact this legislation, and congratulates KMA on its success.

Opioid prescriptions continue to decline

For the fourth consecutive year, total opioid prescriptions have declined in the United States, according to new data from Quintiles IMS. From 2013 to 2016, there was a national 14.6 percent decrease in retail filled prescriptions. Every state saw a decrease. In 2016, there were 215.1 million opioid prescriptions, down from 251.8 million in 2013.

For more information, including a state-by-state breakdown, contact Daniel Blaney-Koen

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Other News

AMA comments on NIST draft cybersecurity framework

The American Medical Association (AMA) recently submitted comments on the National Institute of Standards and Technology's (NIST) proposed update to the Framework for Improving Critical Infrastructure Cybersecurity. NIST is a non-regulatory agency located within the Commerce Department.  NIST's framework is a voluntary, flexible approach to cybersecurity implementation that helps organizations evaluate their own approach to security. 

The AMA urged NIST to contemplate ways to make cybersecurity best practices affordable, attainable and approachable for physicians without extensive health IT knowledge or experience. The AMA website has more information and resources on cybersecurity.

SAFER Guides updated to include strategies on ransomware

The Office of the National Coordinator for Health Information Technology (ONC) has updated its SAFER Guides to include ransomware prevention and mitigation strategies.  The SAFER Guides are designed to help clinicians improve their EHR usability and address other risks associated with the use of health IT. 

Each of the nine SAFER Guides begins with a checklist of recommended practices and contains a practice worksheet providing a rationale for, and examples of, how to implement each recommended practice, as well as fillable fields to record team members and follow-up action. The AMA continues to advocate for easier ways for small and mid-size practices to develop good cyber hygiene. 

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Upcoming Events

April 20:
Learn about the Quality Payment Program created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) by attending an upcoming webinar held by AMA, April 20 at 7 p.m. EDT. This webinar is open to all physicians and Federation staff. Register now.

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