June 29, 2017
Issue SpotlightCMS proposes more flexibility, transition time for QPP's 2nd year
The Centers for Medicare and Medicaid Services (CMS) has released a proposal that could affect how doctors practice next year and how they will be paid in 2020. Year two of the Medicare Quality Payment Program (QPP) could serve as another transition year for physicians adjusting to value-based payment if a proposed rule, released June 20 by CMS, is implemented.
The QPP, created by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), was rolled out this year. Physicians were given four options for their level of implementation under a "pick your pace" approach. These include participating in an Advanced Alternative Payment Model (APM) and three different levels of participation in the QPP's Merit-based Incentive Payment System (MIPS). How physicians perform this year will affect payments in 2019.
The new proposal includes more accommodations for small practices and, if it's implemented as written, CMS estimates 94 percent of eligible clinicians will receive either a positive or neutral adjustment to their Medicare payments in 2020, based on the success of their MIPS participation next year.
The AMA commended CMS for its approach to the second year of the program.
"CMS is proposing a number of policies to help physicians avoid penalties under the Quality Payment Program," said AMA President David O. Barbe, MD. "The Administration showed it heard the concerns raised by the AMA on behalf of practicing physicians. In proposing these rules, the administration has taken another step to make sure the promise of MACRA—where physicians are rewarded for improvement and for delivering high-quality, high-value—will be fulfilled."
A major accommodation to small practices was expanding the low-volume threshold for exemption from MIPS. For 2017, physicians who made $30,000 or less on Medicare Part B charges or saw 100 or fewer Medicare patients are exempt from MIPS quality-reporting requirements. For 2018, CMS proposes tripling the financial threshold, increasing it to $90,000, while doubling the patient threshold to 200.
Read more at AMA Wire®.
National UpdateAMA announces opposition to Senate health system reform
On June 26, the AMA sent a letter to the Senate expressing opposition to the draft Better Care Reconciliation Act (BCRA) that was released on June 22. As was the case with the American Health Care Act, the AMA's opposition to this bill is based on the principles it shared with both chambers of Congress in early January. In particular, the AMA expressed dismay at the loss of coverage and reduced federal support for Medicaid. The AMA's summary of the bill is available on the AMA website.
Subsequently, on June 27, Senate Majority Leader Mitch McConnell announced that this week's planned vote on BCRA has been postponed until after the July 4 Congressional recess, to provide more time for securing the necessary 50 votes for passage.
Read a Leadership Viewpoints column about the AMA's opposition to the proposal from AMA President David O. Barbe, MD, MHA, and listen to an interview with Dr. Barbe on National Public Radio.
This week AMA members can share comments and questions in the AMA Running Your Practice Digital Community, where Advocacy staff are answering questions on the AMA's position on health reform and efforts on the Senate's bill.
On June 26, the Congressional Budget Office (CBO) released estimates of the impact of the BCRA. The version scored by CBO included new language to incentivize individuals to maintain coverage by implementing a six-month waiting period for coverage for persons who had a gap in coverage of more the 63 days in the previous year. Among the CBO's findings:
- The number of uninsured would increase by 22 million in 2026 relative to current law, for a total of 49 million.
- In 2018, about 15 million more people would be uninsured, primarily due to elimination of the individual mandate.
- Average premiums would increase in the nongroup market prior to 2020 compared to current law; after that, premiums are projected to be relatively lower, largely due to the reduced actuarial value of the benchmark plans, which will cover a smaller share of health care services than under current law. CBO estimates that fewer low-income people will purchase plans starting in 2020, despite being eligible for premium tax credits, due to higher deductibles and copayments.
- The deficit would be reduced by $321 billion, largely due to reductions in Medicaid spending (-$772 billion) and changes in the Affordable Care Act's low-income subsidies (-$408 billion), offset by repealed or modified tax provisions ($541 billion) and eliminating the penalty payments ($210 billion).
Some of the provisions that form the core of pending federal health-reform legislation are deeply unpopular in seven battleground states, according to polls of registered voters commissioned by the AMA.
Voters showed widespread support for the traditional Medicaid program that helps poor American adults and 37 million children access care. A majority of poll respondents want Medicaid funding to be increased or maintained at current levels, with those supporting cuts ranging from a minority of 9 percent to 17 percent.
Majorities of those polled in Alaska, Colorado, Nevada, Ohio and West Virginia were opposed to eliminating or reducing federal funding for the expanded version of Medicaid that has enabled millions of low-income Americans to gain insurance coverage in recent years.
The poll also found that the House-passed American Health Care Act (AHCA)—whose major provisions are also found in the Senate proposal—is massively unpopular. No more than 26 percent of voters supported the AHCA in any of the seven states whose voters were surveyed.
Read more at AMA Wire.
On June 28, the House of Representatives passed a comprehensive medical liability reform bill, H.R. 1215, the Protecting Access to Care Act of 2017 (PACA), by a vote of 218 to 210. This bill includes significant reforms that will help repair our nation's broken medical liability system, reduce the growth of health care costs, and preserve patients' access to medical care. The AMA submitted a letter to Congress strongly supporting H.R. 1215.
PACA provides the right balance of reforms by promoting speedier resolutions to disputes, maintaining access to courts, maximizing patient recovery of damage awards with unlimited compensation for economic damages, while limiting non-economic damages to a quarter million dollars. Importantly, H.R. 1215 includes language to protect medical liability reforms enacted at the state level. The CBO determined that H.R. 1215 would reduce federal health care spending by $44 billion over 10 years and reduce the deficit by $50 billion over the same period.
State UpdateNevada governor vetoes harmful balance-billing legislation
Nevada Gov. Brian Sandoval recently vetoed Assembly Bill 382, harmful balance-billing legislation that would have exacerbated access to care issues in Nevada and further imbalanced contract negotiations between physicians and insurance companies. The legislation was strongly opposed by the Nevada State Medical Association, the AMA, the American College of Emergency Physicians and many other medical societies.
In letters to Nevada lawmakers, physicians expressed interest in working with the legislature and the governor to craft a solution to out-of-network billing that will protect patients from unanticipated and financially impactful medical costs, without undercutting incentives for insurers to contact with physicians.
For more information, contact the AMA's Emily Carroll.
The new AMA opioid microsite was updated this week with new education and treatment resources from the American Society of Addiction Medicine (ASAM), Providers' Clinical Support System for Opioid Therapies (PCSS-O) and the Providers' Clinical Support System for Medication Assisted Treatment. The resources include the ASAM "Fundamentals of Addiction Medicine," PCSS-O's "Core Curriculum: Treating Chronic Pain" and more.
The microsite also was updated with a new course from the Medical Society of the State of New York that meets a pending continuing medical educational mandate requirement. The course, "Pain Management, Palliative Care and Addiction Courses," is a series of three modules that meet a New York state requirement for all prescribers of pain-management medication who hold a Drug Enforcement Administration license to take a three-hour, CME-credited course by July 1, 2017.
Nearly all states and 20 national medical and specialty society organizations now have resources on the microsite. If your medical society has education, training or other resources that you would like to see added to the microsite, contact the AMA's Daniel Blaney-Koen.
The AMA and California Medical Association are supporting Assembly Bill 1048, which will be an important part of the state's efforts to reverse opioid-related harms. If enacted, California will be one of the first states in the nation to enact partial fill legislation as part of efforts to reduce unused or unwanted opioid analgesics and other Schedule II controlled substances from the supply chain.
In a letter to the bill author, Assemblymember Joaquin Arambula, MD, AMA Executive Vice President and CEO James L. Madara, MD, highlighted that partial fill legislation "empowers health care professionals—including pharmacists—to have meaningful discussions with patients about the expected duration of pain, and the risks and benefits of prescription opioids. Partial fill also empowers patients to be able to request a lesser amount of a Schedule II controlled substance, which can help ensure that unwanted medications are not able to be diverted. As such, partial fill legislation can be an important component of a state's strategy to end the opioid epidemic."
Dr. Madara also pointed out that California physicians already have made significant strides in making more judicious prescribing decisions. Data from Quintiles/IMS show that from 2013 to 2015, retail-filled opioid prescriptions in California decreased more than 17 percent, and California has the lowest per-capita prescribing rate in the nation. AB 1048 can further complement this important trend.
The AMA last week provided its support for two bills in the New Jersey General Assembly to help bring increased transparency to drug costs and additional oversight of pharmacy benefit management companies (PBMs). Assembly Bill 762 would, among other things, help provide patients with and the legislature with relevant information about the manufacturing, production, research and development, advertising and other associated costs for prescription medications. It would apply to both brand and generic medications.
The AMA also supported Assembly Bill 4676, which would provide important groundwork to regulate PBMs. In a letter to the bill sponsor, Dr. Madara highlighted that "PBMs, which make important decisions about whether a medication will be covered by an employer or health insurer—and at what price—have largely escaped legislative or regulatory scrutiny."
For more information about the New Jersey legislation, please contact the Medical Society of New Jersey's Mishael Azam.
A new report from the Addiction Solutions Campaign revealed the significant challenges that patients face when seeking insurance coverage for treatment for a substance use disorder.
Researchers from the Legal Action Center, National Center on Addiction and Substance Abuse, Treatment Research Institute and the Partnership For Drug-Free Kids reviewed documents from seven small-group, large-group and employer-sponsored health care plans in New York and Maryland to help determine whether plans were meeting the requirements of the Mental Health Parity and Addiction Equity Act of 2008, called the Parity Act for short. The researchers found that:
- Regulators cannot conduct a complete assessment of parity compliance through form review with even a comprehensive data-gathering template, because required information is not available in these documents.
- Consumers cannot ascertain all standards that will determine access to substance use treatment, and are not informed of their rights under the Parity Act.
- Neither consumers nor regulators can identify Parity Act violations from plan documents routinely reviewed for plan approval.
- Prescription drug formularies include wide discrepancies in the coverage of, and restrictions on, medications for the treatment of addiction.
"This report makes it clear that health insurers and regulators need to take a hard look at their legal obligations to ensure that patients receive the full benefits of existing parity laws covering mental health and substance use disorders," said Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force. "While we recognize that some insurers have made steps to remove prior authorization for medication assisted treatment, for example, this report should be a wake-up call that too many patients face significant hurdles in accessing care."
Read the full AMA statement here.
Other NewsFDA announces efforts to increase generic drug competition
In a June 21 post on the Food and Drug Administration (FDA) Voice blog, FDA Commissioner Scott Gottlieb, MD, announced the agency's planned efforts to curb the ability of drug manufacturers to engage in anti-competitive "gaming" of the regulatory system to limit entry of generic competitors into the market. As part of the FDA's forthcoming Drug Competition Action Plan, Dr. Gottlieb intends to target anti-competitive actions of brand manufacturers when those companies engage activities that create obstacles to generic access.
While Dr. Gottlieb states that the agency will look to make changes in both policy and programs at the FDA, anti-competitive actions such as limiting or blocking access to drug samples necessary for essential bioequivalency testing required to gain approval for a new generic drug will be an initial focus of the FDA's efforts. In conjunction with the blog post, the FDA announced a July 18 public meeting where agency officials will seek input from the public on circumstances where generic competition may be thwarted by these types of anti-competitive actions.
The AMA has worked with the administration and Congress to ensure that brand manufacturers are not able to exploit FDA safety programs as a way to limit generic manufacturer access to testing samples in this manner. This is a key priority in its work on generic drug policy. The AMA will continue to work closely with the FDA, Department of Health and Human Services, Federal Trade Commission and Congress to promote access to affordable, effective prescription drugs.
On June 13, 2017, the AMA submitted comments on the 2018 Hospital Inpatient Prospective Payment System (IPPS) and Long Term Care Hospital Prospective Payment System proposed rule. There were many proposals in the rule that the AMA has significant concerns about; however, there are also many proposals included in the rule that the AMA supports.
For example, the AMA's comment letter strongly supported CMS' request for information regarding how the restrictions on physician-owned hospitals affect health care delivery. The letter described the AMA's position that physician-owned hospitals represent the type of coordinated care that is needed for the future of health care delivery, and that these facilities should be able to compete on equal footing with other hospitals in the delivery system.
The AMA also provided support and feedback on CMS' proposals related to the Medicare and Medicaid Meaningful Use programs, including the reduction of the reporting period from a full year to 90-days and the exception for physicians who cannot meet Meaningful Use requirements because their Certified Electronic Health Record Technology (CEHRT) has been decertified.
The rule contained several proposals that concerned the AMA, including a proposal to update the new Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey by replacing previous questions about pain management with new questions that address "Communication about Pain during Hospital Stay." The AMA also provided feedback on a number of individual measures used in the Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs.
In addition, the 2018 Hospital IPPS proposed rule included a request for information on CMS flexibilities and efficiencies. The AMA provided detailed comments on areas where CMS could reduce the regulatory burden for physicians, including prior authorization and utilization management, certification and documentation requirements, appropriate use criteria, increased transparency around electronic health record costs, program integrity issues, and the "two-midnight" policy.
The AMA will provide an update once the 2018 Hospital IPPS final rule is released this fall.