Aug. 24, 2017
Issue SpotlightQPP rule should be simpler, more flexible
On Aug. 21, the AMA submitted a comment letter to the Centers for Medicare and Medicaid Services (CMS) on the Quality Payment Program (QPP) proposed rule for 2018. The comments reflect input from the Federation through both the Merit-based Incentive Payment System (MIPS) and alternative payment model (APM) workgroups.
The letter expresses appreciation for many CMS proposals that address AMA concerns, especially the need for another transition year in 2018 and additional assistance for small and rural practices. Nonetheless, it urges CMS to simplify, provide flexibility, and streamline the program and makes specific suggestions for how to accomplish these goals. The AMA will also continue emphasizing the need to reduce regulatory burden and simplify the QPP in its ongoing dialogue with the agency on this program.
Positive elements of the proposed rule include that it:
- Makes 2018 another transitional year and raises the low-volume threshold exemption to $90,000 or 200 Medicare beneficiaries.
- Initiates virtual groups to enable small practices to combine resources for reporting under MIPS without formally integrating.
- Helps small practices with an exemption from the advancing care information (ACI) component of MIPS and additional bonus points.
- Postpones the mandate for physicians to upgrade to 2015 certified Electronic Health Record technology (CEHRT).
- Maintains rather than increases current requirements for the number of quality measures and data completeness.
- Keeps MIPS cost category's weight at zero in 2018.
There are issues with the proposal, however, that CMS should address in the final rule. The AMA is urging the agency to:
- Set the composite score performance threshold at six rather than 15.
- Exclude Part B drugs from MIPS calculations or payment adjustments.
- Simplify the scoring methodology.
- Provide timely notification to practices that qualify for special exceptions and treatment.
- Ensure methodology and data are sound before scoring practices on data reporting improvement.
- Provide maximum flexibility for virtual groups.
- Modify quality provisions on topped-out measures and benchmarks and eliminate requirements related to outcome measures, all-payer data and administrative claims measures.
- Finalize the zero cost weight for 2018 and keep weight low in next three years.
- Add flexibility to the ACI category, reduce data blocking attestation requirements, and grant physicians ACI credit for using CEHRT to participate in qualified clinical data registries.
- Refrain from adding complexity to the improvement activity category.
- Phase in and then retain the 8 percent revenue-based nominal risk standard for APMs for the foreseeable future.
- Extend the medical home risk standard to small and rural practices participating in all advanced APMs.
- Include medical homes comprised of specialty practices.
Read more in AMA Wire®.
National UpdateSome physicians in line for 2018 penalty eligible for hardship exception
The Medicare Access and CHIP Reauthorization Act (MACRA) ensured that Medicare Meaningful Use (MU) payment adjustments would discontinue in 2019, which is why—given MU's typical two-year look-back period—most physicians participating in MIPS in 2017 do not need to also participate in MU in 2017. However, physicians who have never reported on MU (i.e., physicians who are eligible to participate in MU but have never attested before) will receive a negative payment adjustment in 2018, since the look-back period for first-time reporters is only one year.
To ease the burden on these physicians, the AMA urged CMS to develop a one-time hardship exception, ensuring that first-time reporters in 2017 did not have to simultaneously participate in MU and the ACI component of MIPS simply to avoid a negative payment adjustment in 2018.
While the application and instructions state the physicians must plan on reporting ACI measures in 2017, physicians applying for the hardship exception can still decide to participate in the MIPS "pick your pace" test option—allowing them to report on one quality measure for one patient to avoid a payment penalty in 2019. In other words, physicians who participate in MIPS at the test pace are not required to report data on ACI to use the hardship exemption.
The hardship application allows multiple physicians from one practice to be included on the same application. Physicians or their practice managers can attach the application to an email and send it to firstname.lastname@example.org or fax it to (814) 456-7132. It must be completed and submitted to CMS no later than Oct. 1. Physician practices should save the application for their own records prior to submission.
As a reminder for all eligible Medicare, Medicaid, and hospital-based physicians, CMS now has three separate electronic health record (EHR) incentive programs. Participation requirements, incentives and penalties differ by program. Eligible physicians should be aware of which program applies to them, the incentives that are still available, how to avoid penalties, and the length of the reporting periods.
ACI component of MIPS
- ACI replaces the Medicare Meaningful Use program for "MIPS eligible physicians."
- In 2017, MIPS eligible physicians are defined as those who bill Medicare more than $30,000 in Part B-allowed charges a year and provide care for more than 100 Medicare patients a year.
- MIPS participation can result in up to a 4 percent bonus in 2019, depending on the physician's total MIPS score in 2017.
- The "pick your pace" option in 2017 allows a physician to avoid a negative payment adjustment by "testing" the program; for example, reporting one quality measure on one patient.
- Physicians do not have to participate in the ACI component of MIPS in 2017, but they can at their own discretion. The "test" option for ACI in 2017 is to complete the ACI Base Score measures (see page 4 of this ACI fact sheet).
- There is a 90-day reporting period for ACI in 2017 and 2018.
Medicaid EHR incentive program
- Medicaid-eligible physicians have the option of participating in Modified Stage 2 or Stage 3 MU measures in 2017.
- Medicaid-eligible physicians must meet one of the following:
- Have a minimum 30 percent Medicaid patient volume; or
- Be a pediatrician and have a minimum 20 percent Medicaid patient volume; or
- Practice predominantly in a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) and have a minimum 30 percent patient volume attributable to needy individuals.
- Medicaid-eligible physicians may receive up to $63,750 in incentive payments over the life of the program.
- Medicaid-eligible physicians are not subject to Medicaid MU penalties.
- There are 90-day reporting periods for Medicaid MU in 2017 and 2018.
Medicare-eligible hospitals and critical-access hospitals
- All Medicare-eligible, hospital-based physicians are required to attest to a single set of measures.
- Eligible hospitals decide which MU program to participate in—Modified Stage 2 or Stage 3.
- Hospital-based physicians perform 90 percent or more of their services in an inpatient hospital or emergency room hospital setting.
- There are no Meaningful Use incentives available to hospital-based physicians; eligible hospitals receive incentives directly.
- There are no Meaningful Use penalties for hospital-based physicians; eligible hospitals are subject to penalties directly.
- There are 90-day reporting periods for Medicare Meaningful Use hospitals in 2017 and 2018.
The AMA Opioid Task Force this week released an updated guidance document for physicians and other health professionals to encourage them to co-prescribe naloxone when clinically appropriate.
The updated resource recommends that physicians consider several key questions that the task force believes can be helpful when determining whether to co-prescribe naloxone to a patient, or to a family member or close friend of the patient:
- Is the patient receiving a high dose of opioids?
- Does the patient also have a prescription for a benzodiazepine?
- Does the patient have a history of substance use disorder?
- Does the patient have an underlying mental health or other medical condition that makes him or her more susceptible to overdose?
- Would the patient be in a position to help another person at risk of overdose?
"If it were not for naloxone, it is likely that many thousands more would be dead from an opioid-related overdose," said Patrice A. Harris, MD, MA, AMA Opioid Task Force Chair. "We know that naloxone—by itself—will not reverse the nation's opioid epidemic, but it is a critical component that saves lives and provides a second chance."
The updated guidance document, as well as the AMA opioid microsite, also includes links to multiple resources for physicians to use in their practice—ranging from recommendations for use in different settings, best practices and product comparisons.
Learn more about the Opioid Task Force and its recommendations to end the nation's opioid epidemic.
The Providers' Clinical Support System for Opioid Therapies (PCSS-O) and the Providers' Clinical Support System for Medication Assisted Treatment (PCSS-MAT) recently released several new free resources for primary care physicians and other prescribers in the prevention, identification and treatment of opioid-use disorders (OUD) and co-occurring mental disorders. The Substance Abuse and Mental Health Services Administration-funded projects are led by the American Academy of Addiction Psychiatry and a coalition of many national professional organizations, including the AMA.
PCSS-O recently launched its 14-module core curriculum on pain for primary care physicians and other prescribers who want in-depth, evidence-based knowledge in preventing and treating chronic pain and OUD.
PCSS-MAT clinical experts recently created a series of naltrexone online modules on evidence-based approaches to prescribing naltrexone for the treatment of OUD. Naltrexone is one of three medications approved by FDA for treating OUD.
In addition to webinars and courses (most with CME and CEU), PCSS offers clinicians the unique opportunity to connect with a network of national experts in the fields of pain management and substance use disorders. PCSS-O and PCSS-MAT clinical experts provide support via email, telephone, or in person when viable. PCSS also offers a discussion forum in which clinicians may ask a clinical question and have that question answered by the "Expert of the Month."
Learn more about the free resources now available from PCSS.
State UpdateOregon psychologist prescribing bill vetoed
At the urging of the AMA and others, Oregon Gov. Kate Brown vetoed a bill that would have made Oregon the sixth state to allow psychologists to prescribe psychotropic medication and interpret laboratory tests. In a letter to the governor, AMA Executive Vice President and CEO James L. Madara, MD, expressed the AMA's concerns with the legislation, Oregon House Bill 3355.
"While the AMA values the role that psychologists play in our nation's health care system," the proposal "would risk patient safety and expose patients, including children and adolescents, to inadequate health care," Dr. Madara wrote.
This victory would not have been possible without the work of the Oregon Medical Association (OMA) and American Psychiatric Association (APA). The AMA is proud to have partnered with OMA and APA in these efforts, and congratulates them both on their success.
On Aug. 9, Oregon Gov. Brown signed legislation raising the minimum age for buying tobacco products to 21. Under the new law, individuals under the age of 21 are prohibited from purchasing tobacco products as well as inhalant delivery systems (commonly known as e-cigarettes or vapes). Store clerks who sell these products to people under 21 will face fines ranging from $50 to $1,000.
The AMA supports the passage of laws that set the minimum age for purchasing tobacco products, including e-cigarettes, at 21 years. In 2015, the Institute of Medicine found that increasing the minimum legal age for tobacco products would prevent or delay initiation of tobacco use by adolescents and young adults because they are less likely to be in the same social networks as adults over the age of 21, making it more difficult for them to obtain tobacco products.
In passing the law, Oregon became the fifth state to raise the minimum purchasing age to 21. California, Hawaii, Maine and New Jersey have passed similar legislation. The laws are the result of a nationwide movement to reduce tobacco use by young people.
The Texas House of Representatives adjourned special session on Aug. 15 without passing Senate Bill 3, effectively killing the measure. SB 3 would have required people to use restrooms, showers and changing rooms in public schools and other state and local government facilities that match the sex on their birth certificate or driver's license, as opposed to their gender identity. The measure was criticized as being discriminatory against transgender people.
In June, the AMA House of Delegates adopted policy opposing "policies preventing transgender individuals from accessing basic human services and public facilities in line with one's gender identity, including […] the use of restrooms." AMA policy further advocates for the creation of policies that "promote social equality and safe access to basic human services and public facilities for transgender individuals according to one's gender identity."
Judicial UpdatePDMP case pits patient privacy against law-enforcement intrusion
Fear that law-enforcement scrutiny may deter a patient from seeking medical treatment or make a physician reluctant to prescribe pain medications to patients is "speculative," a federal appeals court ruled recently in a case regarding the privacy of records held in prescription drug-monitoring databases. Concern about potential privacy intrusion doesn't qualify as an imminent injury that can be addressed in court, the court said.
On this and other procedural grounds, a three-judge panel from the 9th U.S. Circuit Court of Appeals reversed a U.S. District Court ruling that prohibited the U.S. Drug Enforcement Administration (DEA) from accessing records in the Oregon Prescription Drug Monitoring Program (PDMP) without a warrant based on probable cause.
The legislation that created the Oregon PDMP in 2009 stipulated that law-enforcement access be allowed only after the issue of a court order based on probable cause requested by a law-enforcement investigation involving the "person for whom the requested information pertains."
So, when the DEA attempted to access the database using administrative subpoenas not subject to judicial review, the Oregon PDMP refused to comply—stating that it would be against state law to do so. The state agency also sued in federal court for a judgment on whether the federal subpoena could override state law.
The American Civil Liberties Union Foundation of Oregon, along with a physician and four patients, intervened in the case arguing that the Fourth Amendment of the U.S. Constitution granted them a reasonable expectation of privacy over their confidential medical records.
"It is difficult to conceive of information that is more private or more deserving of Fourth Amendment protections," U.S. District Judge Ancer Haggerty wrote in his Feb. 11, 2014, ruling.
The DEA appealed, arguing that the risk of public disclosure stemming from a future records request was "especially non-imminent and speculative" and that their request for PDMP data did not "unreasonably intrude upon any legitimate privacy expectation" as medical information is "regularly shared with a variety of third parties."
"Whatever right to privacy an individual may have in his medical information, it is not absolute," the DEA stated in its appellate reply brief.
The Litigation Center of the American Medical Association and the medical association from the states covered by the 9th Circuit (Alaska, Arizona, California, Hawaii, Idaho, Montana, Nevada and Oregon) filed an amicus brief in support of the Oregon PDMP and the interveners. The brief advised the court that unwarranted disclosure of PDMP data could compromise care.
The brief specifically argued against the DEA point that patient information is already regularly shared.
"The patient's high expectation of privacy is not diminished when a patient fills a prescription provided by her physician for her treatment, merely because the state then collects and centralizes that data," the Litigation Center brief stated.
Read more at AMA Wire.
Starting at noon CDT, the AMA will host the webinar "How to Position Yourself as a Physician Leader" (1.0 AMA PRA Category 1 Credits™), a timely and empowering webinar for women physicians. Despite the increasing number of women in medicine, women physicians continue to hold a smaller proportion of leadership positions. Author, researcher and educator Vineet Arora, MD, will share strategies on how women physicians can better position themselves as leaders. Dr. Arora will discuss highly relevant topics including contract and salary negotiations, and career advancement strategies. Registration is open until Sept. 10.
Apply by Sept. 8 to attend the Candidate Campaign School and become an advocacy expert at the AMA office in Washington, D.C. The school is targeted to AMA members, their spouses, residents, medical students and medical society staff who want to become more involved in the campaign process. Faculty, materials and meals are covered by AMPAC. Participants are responsible for the registration fee ($350 for AMA members, $1,000 for nonmembers), airfare and hotel accommodations. Learn more or apply, or contact us at: email@example.com.
Jan. 4–6, 2018:
The AMA State Legislative Strategy Conference takes place at the Sanibel Harbour Marriott Resort and Spa near Fort Myers Beach in Florida. Email firstname.lastname@example.org for more details.
Feb. 12–14, 2018:
The AMA National Advocacy Conference will be held in Washington, D.C. at the Grand Hyatt Washington. Email email@example.com for more details.