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Nov. 14, 2019

Issue Spotlight

5 things doctors need to know about 2020 Medicare fee schedule

The 2020 Medicare physician payment schedule contains news about coding revisions for outpatient evaluation and management (E/M) services that promise to greatly reduce administrative burdens for physicians in 2021. But the 2,475-page document  also contains information on a multitude of tweaks to the Medicare Quality Payment Program (QPP) and a plethora of other details affecting how physicians will be paid by Medicare starting Jan. 1.

The AMA's experts have prepared a summary of the 2020 changes to QPP and Medicare physician payment. Here are five things physicians need to know.

A heavier lift will be required to avoid a MIPS penalty. The Centers for Medicare & Medicaid Services (CMS) raised the minimum score needed to avoid a penalty for physicians participating in the QPP's Merit-based Incentive Payment System (MIPS) to 45 points from 30. The maximum penalty, which would affect 2022 payment, will be raised to 9% from 7%. In addition, CMS set the minimum score for 2021 at 60.

Raising the performance threshold is expected to lead to corresponding growth in the cost of MIPS compliance, but statistics also show that more clinicians are scoring at the high end of the scale than at the low end. For calendar year 2018, which will determine payment levels for 2020, CMS said the average score was 86.9 and 99.6 was the median. This far exceeded CMS projections of 80.3 and 90.9.

MIPS high-performer threshold goes up. Clinicians deemed "high performers" are eligible to split an additional $500 million in available bonus money. CMS proposed setting the 2020 high-performer threshold at 80 points but raised it in the final rule to 85.

"We believe it is important to incentivize exceptional performance in MIPS," the final rule states. "This adjustment would raise the bar on exceptional performance and provide an appropriate financial incentive for high performers."

CMS estimates 92.5% of the 880,000 MIPS-eligible clinicians will avoid a penalty or earn an incentive payment, with 45% eligible for the exceptional performance bonus.

No change to MIPS cost and quality weights. CMS had proposed lowering the weight of quality measures in MIPS scoring from 45% to 40% while raising the weight of cost measures from 15% to 20%. The final rule states that those weights will remain the same.

In the final rule, CMS said it agreed with the AMA concern about the lack of detailed, timely and actionable feedback on cost measures.

"We are committed to improving the feedback experience, including aiming to provide more granular and real-time data, for clinicians to better understand how they can improve their performance on these measures and in turn reduce the cost of care for Medicare beneficiaries," the rule states. "Once clinicians better understand and are more accustomed to reviewing the performance feedback reports on these episode-based and global cost measures, we would then expect to increase the cost performance category weight."

The AMA also remains concerned about Medicare Spending Per Beneficiary and Total Per Capita Cost measures as they hold physicians responsible for costs that they have little control over. CMS said this approach "helps to align incentives across care settings through the patient care continuum, which encourages care coordination."

Bonus points for are still available for small practices and for those serving "complex patients," defined as those with high medical risk or with dual Medicare-Medicaid eligibility.

Framework to cut MIPS burdens. CMS is moving ahead with MIPS Value Pathways, which—starting in 2021—will create a framework to reduce the complexity and administrative burdens associated with MIPS.

CMS is looking to eliminate the reality that the four MIPS reporting categories seem like four different programs and replace it with a pathway that:

The AMA is committed to working with CMS and specialty societies to shape the pathways with the goal of making MIPS less complex and burdensome and more clinically relevant.

APM 2022 payments estimated, 2019 payments paid. CMS estimates that between 210,000 and 270,000 clinicians will be eligible Qualifying APM Participants in 2020 and exempt from MIPS reporting requirements. It also estimates that APM incentive payments will total between $535 million and $685 million.

Five percent APM incentive payments earned in 2017 have only recently been paid. The AMA joined eight other organizations in a September letter to CMS protesting the delay in payment.

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National Update

HHS proposes to stop enforcing sexual orientation and gender identity anti-discrimination terms in grant conditions

The U.S. Department of Health and Human Services (HHS) has released a proposed rule that would modify the Uniform Administrative Requirements, Cost Principles and Audit Requirement for HHS Awards (i.e., grant conditions for HHS grants). These grants provide $500 billion in funding annually for programs including STD/HIV prevention and care, early childhood education, adoption and foster care, community health centers, community mental health and opioid treatment programs and youth homelessness programs, among others. The proposal seeks to modify several current grant conditions, including one that prohibits discrimination on the basis of sexual orientation and gender identity (SOGI), because HHS states that it has heard concerns that the current regulations violate the Religious Freedom Restoration Act and the Constitution. Specifically, HHS proposes to replace the SOGI anti-discrimination provision with one that prohibits discrimination against classes named by federal statute, such as discrimination based on sex. Many federal agencies and courts have interpreted "sex discrimination" as including discrimination based on SOGI, and the Supreme Court has held that discrimination based on stereotypical notions of appropriate behavior, appearance, or mannerisms for each gender (i.e., "sex stereotypes") constitutes sex discrimination. However, there is not a federal statute explicitly prohibiting discrimination based on SOGI. The proposal is clearly intended to embolden grantees to refuse services to clients or patients who the grantee finds objectionable—for example, grantees could refuse to place foster children with gay parents or refuse to provide care to transgender individuals. HHS also stated that as of Nov. 1, it will no longer enforce the current SOGI anti-discrimination grant conditions.

The proposal is open for comment for only 30 days. The AMA will submit comments reiterating its strong opposition to discrimination based on an individual's sex, sexual orientation, gender identity, race, religion, disability, ethnic origin, national origin or age and any other such policies.

Judge vacates "conscience rule" that sought to create rights to refuse care

On Nov. 6, a federal district court judge in the Southern District of New York vacated the so-called "conscience rule" that revised existing regulations and created new regulations to interpret and enforce more than 20 federal statutory provisions related to conscience and religious freedom. The rule would have permitted individuals, health care organizations and other entities to refuse to provide or participate in medical treatment, services, information and referrals to which they have religious or moral objections. The regulation would have impacted services related to abortion, contraception (including sterilization), vaccination, end-of-life care, mental health, global health support and health care services provided to patients who are lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ).

The AMA opposed the rule and urged HHS to withdraw it. While the AMA supports the legitimate conscience rights of individual health care professionals, the exercise of these rights must be balanced against the fundamental obligations of the medical profession and physicians' paramount responsibility and commitment to serving the needs of their patients. As advocates for our patients, AMA strongly supports patients' access to comprehensive reproductive health care and freedom of communication between physicians and their patients, and opposes government interference in the practice of medicine or the use of health care funding mechanisms to deny established and accepted medical care to any segment of the population. The AMA will continue to monitor the issue, including whether the government appeals the ruling.

CMS to apply extreme circumstance policy to clinicians affected by hurricane Dorian

In response to the Federal Emergency Management Agency (FEMA) designation of Hurricane Dorian as a national disaster, CMS has determined that the automatic extreme and uncontrollable circumstances policy will apply to Merit-based Incentive Payment System (MIPS) eligible clinicians in FEMA-identified North Carolina and South Carolina areas.

MIPS eligible clinicians in these areas will be automatically identified and receive a neutral payment adjustment for the 2021 MIPS payment year. During the data submission period for the 2019 performance period (Jan. 2, 2020 to March 31, 2020), all four performance categories for these clinicians will be weighted at 0%, resulting in a score equal to the performance threshold. However, if MIPS eligible clinicians in these areas choose to submit data on two or more performance categories, they will be scored on those categories and receive a 2021 MIPS payment adjustment based on their 2019 MIPS final score.

The automatic extreme and uncontrollable circumstances policy will not apply to MIPS eligible clinicians in MIPS Alternative Payment Models (APMs) who are subject to the APM scoring standard for the 2019 performance period, or to those participating in MIPS as groups or virtual groups.

For More Information visit the Extreme and Uncontrollable Circumstances Overview section on the MIPS > About Exception Applications page or contact the Quality Payment Program Service Center at (866) 288-8292/TTY (877) 715-6222, Monday through Friday, 8:00 a.m. ‒ 8:00 p.m. Eastern Time or by email at qpp@cms.hhs.gov. To receive assistance more quickly, consider calling during non-peak hours—before 10 a.m. and after 2 p.m. ET

DEA launches the Suspicious Orders Report System for controlled substances

On Oct. 23 the Drug Enforcement Agency launched the Suspicious Orders Report System (SORS) which is a new centralized database required by the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act). The SUPPORT Act requires that all DEA registrants that distribute controlled substances to report suspicious orders to the DEA. Reporting a suspicious order to the centralized database established by DEA (SORS Online) constitutes compliance with the reporting requirement under 12 U.S.C 832(a)(3). The term 'suspicious order' may include an order of a controlled substance of unusual size, an order of a controlled substance deviating substantially from a normal pattern and orders of controlled substances of unusual frequency. Reporting to SORS Online satisfies the requirement to report such orders to the Administrator of the DEA and the Special Agent in Charge of the Division Office of the DEA for the area in which the registrant is located or conducts business.

DEA registrants that are already ARCOS Online and ARCOS EDI reporters should use their current ARCOS log on information to access the system. DEA registrants who are not currently ARCOS reporters will need to register on the website in order to report to SORS. The registration process is as follows:

  1. Go to https://apps2.deadiversion.usdoj.gov/arcos-online and click on "SORS Registration (for Non-ARCOS Reporters)" hyperlink.
  2. After completing the initial registration, a confirmation e-mail will be sent to the e-mail address provided.
  3. Once DEA approves the registration, another e-mail will be sent with a temporary password.
  4. Go to https://apps2.deadiversion.usdoj.gov/arcos-online and type in your username and the temporary password. The system will require you to change the temporary password.
  5. Upon successfully changing the password, the account will be fully registered to report to the SORS Online system.

For more information, contact deadiversionwebmaster@usdoj.gov

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State Update

Physicians and patients mobilize behind prior authorization legislation in Michigan

Last week, Michigan lawmakers introduced Senate Bill (S.B.) 612, legislation to reform the prior authorization and step therapy processes. The legislation addresses critical problems with these common utilization management programs including the lack of transparency and clinical validity in the requirements, as well as the delays in care that often have serious consequences for patients.

Nationally, there continues to be every indication that prior authorization requirements are increasing and expanding. Physicians are troubled and frustrated by the overstepping of insurers into the clinical decision-making process and with the time, money and energy spent on ensuring their patients can access covered drugs and services. The AMA released its Prior Authorization Physician Survey earlier this year, and of the practicing physicians surveyed, over 90 percent report care delays associated with prior authorization. But most concerning is that 28 percent of respondents reported that prior authorization has led to a serious adverse event for their patients.

Recognizing the harmful impact of these prior authorization programs, the Michigan State Medical Society helped form a broad coalition of stakeholders, including patients, physicians and other providers. The Health Can't Wait coalition is working to educate lawmakers and the public about the need for immediate reform through meetings, action alerts, news conferences, story sharing and even mobile billboards.

Health Can't Wait

A Health Can't Wait mobile billboard

For more information on this coalition visit www.healthcantwait.org or follow them on twitter.

And for more information about the AMA's efforts on prior authorization or to share your story about prior authorization, visit www.fixpriorauth.org.

Survey finds prior authorization rampant barrier for patients with pain

For the second year in a row, more than 90% of pain medicine specialists said that they have been subject to prior authorization (PA) barriers when trying to provide non-opioid pain care for their patients. The findings come from a recent survey by the American Board of Pain Medicine (ABPM). Prior authorization was common for treatments ranging from physical therapy, pain creams and patches, non-opioid medications and non-opioid pain treatments such as TENS, facet blocks and spinal cord stimulation.

"Prior authorization in some cases may be understandable to help ensure coverage benefits or coordinate complex care, but when it is used almost universally like this, it seems that the real purpose is to discourage physicians and patients from seeking non-opioid pain care," said Mitchell J. Cohen, MD, ABPM President.

The survey also found that 72% of pain medicine specialists said that they—or their patients—have been required to reduce the quantity or dose of medication prescribed, a reduction from the 83% forced to do this as reported by the 2018 ABPM survey. The effects of the reductions have included withdrawal, anxiety and depression as well as suffering with increased pain.

The ABPM also found the effect on physicians' practices equally severe with two-thirds of survey respondents saying that they have had to hire additional staff just to handle prior authorization requirements.

For more information, please contact The ABPM's Mike Slawny at mikeslawny@abpm.org

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Other News

Opioid CME "What Every Prescriber Should Know: What's new for 2020" now available

An update to the primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know includes new information such as:

  • An overview of the current state of the opioid overdose epidemic and opioid prescribing with updated statistics and trends
  • Updates on resources related to the practice environment including the CDC pocket opioid tapering guide
  • New expanded section on Risk Mitigation Strategies for safer opioid prescribing
  • CDC Opioid Prescribing Guideline 2019 Clarification statement
  • Highlights from the 2019 Health and Human Services Pain Care Best Practices Interagency Task Force Report
  • Reiteration of the association between prescription opioids, opioid use disorder, opioid overdose and use of illicit opioids
  • Including non-stigmatizing language

The new opioid primer is worth .75 AMA PRA Category 1 CME. Access it, along with the entire suite of opioid CME on the AMA Ed Hub page.

Physicians are putting advocacy into action in the latest AMA Moving Medicine

AMA members take on some of toughest challenges impacting patients. Read the Fall 2019 issue to discover how your colleagues are developing solutions to critical issues like human trafficking, the opioid epidemic and the spread of health misinformation. Read the Advocacy issue here.

Erick Eiting, MD
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Upcoming Events

AMPAC presents an insiders "How to" guide to running and winning a campaign at I-19

Nov. 17: Ever wondered how physicians get elected to public office? Ever considered a run for office yourself? Attend an in-depth preview of the AMPAC's annual "Candidate Workshop" political education program at this year's Interim Meeting in San Diego. Led by Eva Pusateri, lead consultant and trainer for the AMPAC Candidate Workshop, this session will preview the intensive two-day Candidate Workshop which provides the tools needed to run a winning political campaign. The program is designed to help bridge the gap from the exam room to campaign trail and provide the strategic advantage needed to make a run for public office. Nov. 17, 3–4 pm PT in the Cortez Hill A/B Meeting Rooms.

Jade Simmons announced as the keynote speaker for the AMA State Advocacy Summit

Jan 9–11: Classical pianist and inspirational speaker Jade Simmons will give the keynote address at the 2020 State Advocacy Summit. Simmons received training in piano performance from Northwestern and Rice University. She has performed at The White House and received the Sphinx Organization's Medal of Excellence in a concert held at the US Supreme Court. Named one of the "Best Keynote Speakers of 2019" by Northstar Meetings, her main-stage keynote presentations are a combination of musical performance and storytelling.

Erick Eiting, MD

Keynote speaker Jade Simmons

Register today for the State Advocacy Summit in Bonita Springs, FL Jan. 9-11 at the Hyatt Regency Coconut Point Resort and Spa.

Register now for 2020 AMA advocacy conferences and save 20%

The 2020 AMA State Advocacy Summit will be held in Bonita Springs, Florida, at the Hyatt Regency Coconut Point Resort and Spa, Jan. 9-11. The 2020 AMA National Advocacy Conference will be held in Washington, D.C., at the Grand Hyatt, Feb. 10-12. Register now for both meetings before Dec. 20 using the code "SASNAC20" to save 20% on dual registration.

Register today for the Rx Drug Abuse and Heroin Summit

April 13-16: The Rx Drug Abuse & Heroin Summit is the largest and most-recognized conference committed to addressing the opioid crisis. Government officials, first responders, law enforcement personnel, clinicians, physicians, nurses, educators, public health and prevention officials, and families and people in recovery are represented. The conference agenda is designed with timely and relevant information to address what is working in prevention, treatment and law enforcement. This year's summit will take place in Nashville, TN, April 13-16.

Register today and save an additional $50 with code ALUM.

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