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June 1, 2017

Issue Spotlight

Physician-owned practices dip below 50 percent

Less than half of practicing physicians own their own practice, according to 2016 data collected in a nationally representative survey of 3,500 U.S.-based physicians who provide at least 20 hours of patient care per week and are not employed by the federal government.

2016 marks the first year in which physician practice ownership is no longer the majority arrangement. According to data drawn from the AMA's Physician Practice Benchmark Surveys, 47.1 percent of physicians are practice owners. The same percentage of physicians are employed, while 5.9 percent are independent contractors.

The data reflect a trend that has been evident in recent years. In 2012, the first year in which this AMA survey was conducted, 53.2 percent of physicians were owners. That figure dropped three percentage points to 50.8 percent in 2014. The AMA conducted similar surveys in the 1980s, when physician practice ownership was the dominant arrangement. For example, in 1983, by comparison, 76.1 percent of physicians were practice owners, as noted in a 2015 report.

"Patients benefit when physicians practice in settings they find professionally and personally rewarding, and the AMA strongly supports a physician's right to practice in the setting of their choice," said AMA President Andrew W. Gurman, MD. "The AMA is committed to helping physicians navigate their practice options and offers innovative strategies and resources to ensure physicians in all practice sizes and setting can thrive in the changing health environment."

Read more at AMA Wire®.

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National Update

Senate deliberates on health-system reform legislation

The Senate has begun deliberations on drafting health-system reform legislation that will comport with the procedural rules associated with budget reconciliation legislation. On May 24, the Congressional Budget Office (CBO) released a revised score for the American Health Care Act (AHCA) (H.R. 1628). The CBO stated that the House-passed version of the bill would reduce the federal deficit by $119 billion over 10 years and increase the number of uninsured people relative to current law by 23 million in 2026.

Under the budget rules, the Senate health care reform legislation will be required to save at least as much as the House measure. Now that the CBO has rescored the House-passed bill, the Senate parliamentarian will begin the process of examining H.R. 1628 to determine which provisions of the bill meet the requirements of the Senate budget-reconciliation rules. The rules generally require that provisions in the bill must have a direct effect on the federal budget. It is possible that some provisions of the House-passed version of the AHCA will be stripped away during this process before the bill is considered on the Senate floor.

Separately, on May 23, the AMA sent Senate Finance Committee Chairman Orrin Hatch a letter in response to his May 12 request for recommendations on health system reform. The letter restates the AMA's objectives for health reform legislation, such as ensuring that any proposals to replace portions of current law do not result in individuals who currently have coverage becoming uninsured. The letter makes specific suggestions to improve the health care system in the areas of tax-credit structure and health insurance affordability, stabilizing the individual market, and Medicaid.

It is not yet known when the Senate will consider its version of health care reform legislation. The AMA will continue to work with the Senate to advance proposals consistent with AMA policy and AMA health care reform objectives.

Read more at AMA Wire.

Chronic care legislation advances out of key Senate committee

On May 18, the Senate Finance Committee voted unanimously to advance the Creating High-Quality Results and Outcomes Necessary to Improve Chronic (CHRONIC) Care Act of 2017 (S. 870), sponsored by Chairman Hatch, R-Utah, Ranking Member Ron Wyden, D-Ore., and Sens. Isakson, R-Ga., and Warner, D-Va. 

This AMA-supported legislation would provide a clear pathway in the Medicare program toward new delivery models that are patient-centered and would improve health outcomes and value for patients with chronic conditions. S. 870 would remove barriers to care coordination, enhance the ability of beneficiaries to be a part of an accountable care organization (ACO), and extend and expand the Independence at Home Demonstration program. Further, this bill would expand Medicare telehealth coverage for patients who are suffering from acute stroke or who need dialysis, as well as Medicare Advantage plans and certain ACOs. It is unclear when this legislation will be considered in the full Senate.

Legislation expanding Medicare telehealth coverage introduced in the House and Senate

On May 3, Sens. Schatz, D-Hawaii, Wicker R-Miss., Cochran, R-Miss., Warner, D-Va., Thune, R-S.D., and Cardin, D-Md., introduced the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2017 (S. 1016). On May 19, Reps. Black, R-Tenn., and Welch, D-Vt., introduced a House companion bill, H.R. 2556. The AMA strongly supports this legislation and worked closely with the sponsors in drafting it.

The legislation would remove antiquated restrictions in the Medicare program that prevent the delivery of clinically validated telehealth services and procedures. Increased access to telehealth and remote patient monitoring services is urgently needed to effectively address the looming demographic health demands that will be placed on the Medicare program and physicians in the near future.

The CONNECT for Health Care Act would establish a meaningful pathway to expand Medicare coverage of telemedicine and remote patient monitoring services while addressing concerns regarding the potential for increased expenditures. This legislation would expand Medicare telehealth coverage for Medicare Advantage (MA) plans, certain ACOs and patients who are suffering from acute stroke or need dialysis. Similar provisions were included in S. 810, the CHRONIC Care Act. Further, essential to promoting patient interests, the bill contains provisions that would ensure adherence to important state-based laws relevant to enforcing the oversight of medical practice laws, as well as safeguard the network adequacy of MA plans. It is unclear when this legislation might be considered in the Senate or House.

AMA-led advocacy efforts secure changes to Social Security Number Removal Initiative

In direct response to AMA advocacy efforts and continued engagement with agency officials on the implementation of the Social Security Number Removal Initiative (SSNRI), CMS announced May 30 that it will develop and implement a look-up tool for providers and patients to obtain a beneficiary's new Medicare Beneficiary Identifier (MBI). This change will address concerns expressed by multiple state and specialty associations about patient and physician awareness of initiative's transition to new Medicare identification cards. Physicians will need a Medicare Administrative Contractor (MAC) Portal account to access the look-up tool.  

In addition to the new look-up tool, which will be available in October 2018, CMS plans to begin its patient and provider education efforts earlier than originally planned. Physicians should expect a significant outreach effort over the second half of 2017 to prepare for the start of the transition period in April 2018. CMS also plans to develop fact sheets and resources for physicians to educate patients, which it will make available on its SSNRI homepage

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State Update

Maryland holding statewide opioid education sessions

The Maryland State Medical Society (MedChi) Center for a Healthy Maryland is holding trainings throughout the state to familiarize physicians with the Screening, Brief Intervention, and Referral to Treatment (SBIRT) program and Prescription Drug Monitoring Program (PDMP) of the Department of Health and Mental Hygiene and the Substance Abuse and Mental Health Services Administration. The trainings, which will occur in four key state regions, are free and provide continuing medical education credits. They will take place between May 24 and June 22.

In addition to supporting physicians' efforts to enhance their education, MedChi also was heavily engaged in new bills signed by the governor, as well as issuing a recent report showing yearly decreases in opioid prescribing in Maryland and increases in PDMP use by physicians and other health care professionals.

For more information about efforts in Maryland, please contact MedChi's Gene Ransom

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Judicial Update

Court ruling imperils immunity for physicians in public service

Darshan R. Phatak, MD, a Texas medical examiner, followed the standard of care in compiling an autopsy report for a woman who had died from a gunshot wound. He reviewed investigator reports, photos of the scene and toxicology reports. He also reviewed the gunshot residue testing and the woman's psychiatric history. Among other things, he talked to law enforcement about the case. His report concluded that the woman had died from a homicide.

The woman's former husband, Noel T. Dean, was then tried for his wife's death. This trial concluded with a hung jury. Dean was then retried. Following Dr. Phatak's cross-examination in the second trial, the medical examiner's office changed the autopsy report conclusion to indicate the cause of death was "undetermined." The charges against Dean were abruptly dropped.

Dean then sued Phatak, along with several other government officials and agencies, for violation of his federal civil rights. Phatak moved for summary judgment, arguing that he was entitled to immunity from suit because he had fulfilled his duties as a medical examiner in good faith. However, the U.S. District Court for the Southern District of Texas said that Dean could proceed with his civil rights lawsuit against Phatak. The lower court said qualified immunity did not apply, analogizing Dr. Phatak's case to ones in which medical examiners intentionally fabricated evidence.

Dr. Phatak is asking the 5th U.S. Circuit Court of Appeals in New Orleans to overturn the lower federal court decision in Dean v. Phatak that allowed the civil rights lawsuit to proceed. The Litigation Center of the AMA and State Medical Societies, along with the National Association of Medical Examiners, College of American Pathologists, Texas Medical Association and Texas Society of Pathologists, filed a friend-of-the-court brief asking the court to apply qualified immunity in Dr. Phatak's case. The amici are "greatly concerned" the lower court's ruling will have a "significant chilling effect" on forensic pathologists and other government-employed physicians.  

Read more at AMA Wire.

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Other News

"One patient, one measure, no penalties" kicks off in June

The AMA is planning a week of coordinated communications with the Federation about the Quality Payment Program's (QPP) "Pick your pace" options for reporting. The QPP is the new physician payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA) and is administered by the Centers for Medicare and Medicaid Services (CMS). Because the QPP is new this year, the AMA wants to make sure physicians know what they have to do to participate. This is especially important for those physicians who have not participated in past Medicare reporting and programs and may be less knowledgeable about the steps they can take to avoid being penalized under the QPP.

The AMA stressed to CMS the importance of establishing a transition period to QPP and, as a result, physicians only need to report on at least one quality measure for one patient during 2017 in order to avoid a payment penalty in 2019.

The AMA is creating a short video, "One patient, one measure, no penalty: How to avoid a Medicare payment penalty with basic reporting," along with written guidance that will walk physicians and practice managers through the specific steps for reporting on one patient and one measure this year so they can avoid being penalized under the QPP in 2019. This video will be promoted in June, leading up to "One patient, one measure, no penalties," which kicks off the week of June 26.  

The AMA will be sending further information to its Federation partners so they can help raise physician awareness of what they need to do this year under the QPP. The AMA is hoping this "surround sound" approach, coupled with the practical video guidance, will prepare physicians well. Learn more about MACRA.

CMS releases new resources to help clinicians successfully participate in QPP

CMS has recently revamped the look of the QPP website and also posted new resources to help clinicians successfully participate in the first year of the QPP. The following new resources have been posted to the website:

CMS releases "CAHPS for MIPS" conditionally approved survey vendor list

Physicians who plan on reporting the CAHPS for MIPS measure as one of their quality measures to satisfy MIPS requirements in 2017 must use a CMS-approved CAHPS for MIPS survey vendor. As conditionally approved survey vendors, these organizations have demonstrated they have the facilities, project experience and staff expertise required to conduct the 2017 survey administration with appropriate rigor, given the demands of the survey procedures and timeline.

Final approval of these organizations is dependent on satisfactory completion of CMS training and submission of a Quality Assurance Plan. A final list of the CAHPS for MIPS survey vendors approved by CMS to administer the 2017 survey will be made publicly available this summer.

Keep in mind, physicians who are reporting the CAHPS for MIPS measure must register and inform CMS by June 30, 2017.

Forecast for QPP measure development cooperative agreements

Based on AMA advocacy efforts, MACRA specifically authorizes $75 million through 2019 to fund the development of physician quality measures for use in MIPS or APMs.

CMS recently announced its intention to provide funding assistance specifically for physician specialty societies and physician-led measure developers with working knowledge in quality measure development. The focus of the funds is to develop, improve, update or expand quality measures for use in the QPP under MIPS or APMs.

The tailoring of these funds by CMS to specialty societies and physician-led measure developers is based on extensive feedback from the AMA to CMS. The AMA emphasized to CMS that QPP success is contingent upon all physician specialties having a sufficient set of actionable and relevant measures and the importance of harmonizing measures with specialty societies' clinical data registry activities, as well as complementing specialty-developed alternative payment models. For more information on this grant opportunity, search for CFDA No. 93.986 on Grants.gov.

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