May 2017

MIPS Participation Status Letter and Online Tool Released CMS is reviewing claims and letting practices know which clinicians need to take part in the Merit-based Incentive Payment System (MIPS), an important part of the new Quality Payment Program (QPP). In late April through May, you will get a letter from your Medicare Administrative Contractor that processes Medicare Part B claims, providing the participation status of each MIPS clinician associated with your Taxpayer Identification Number (TIN).  

CMS also released an online tool to see if you are eligible. The tool is available here.  

Clinicians should participate in MIPS in the 2017 transition year if they:

  • Bill more than $30,000 in Medicare Part B allowed charges a year and
  • Provide care for more than 100 Part B-enrolled Medicare beneficiaries a year

QPP intends to shift reimbursement from the volume of services provided toward a payment system that rewards clinicians for their overall work in delivering the best care for patients. It replaces the Sustainable Growth Rate formula and streamlines the “Legacy Programs” – Physician Quality Reporting System, the Value-based Payment Modifier, and the Medicare Electronic Health Records Incentive Program. During this first year of the program, CMS is committed to working with you to streamline the process as much as possible. Our goal is to further reduce burdensome requirements so that you can deliver the best possible care to patients. Learn more about the Quality Payment Program.  

American Health Care Act Passed by House

The American Health Care Act passed the House of Representatives by a narrow 217-216 vote. While the vote was along party lines, a slim minority of Republicans defied Leadership and opposed the bill. The ACHA is the first step in repealing and replacing the Affordable Care Act. The bill is now with the Senate. Early reports are showing that the Senate will either provide major amendments to the ACHA or completely rewrite the bill. The final bill is expected to be completed by the summer recess in July.   The following is a breakdown of the components of the ACA and changes the ACHA will make should it become law.

  • Pre-existing conditions
    • ACA: People get health insurance coverage on their own can no longer be turned for coverage because of pre-existing conditions. Insurers cannot charge them higher premiums because of their health
    • AHCA: Insurers would still be required to cover people with pre-existing conditions. However, states may apply for waivers to allow insurers to charge them higher premiums, starting in 2019, if the states have backup programs, high-risk pools, to cover sick people. The state run high-risk pools is referred to as the MacArthur Amendment.  The Upton Amendment increased funding for these pools by $8 billion.
  • Exchanges
    • ACA: The ACA established exchanges or market places to offer health plans and determine eligibility for tax credits. Twelve states operate their own exchanges, while the remaining states use the federal marketplace,
    • AHCA: The AHCA does not eliminate the exchanges, however the Congressional Budget Office (CBO) predicts that fewer insurers would participate due to the fact that they would not have to offer plans through these exchanges for people to get subsidies.
  • Young Adult Coverage
    • ACA: Young adults can stay on their parents’ health insurance plans until age 26.
    • AHCA: No changes
  • Individual Mandate
    • ACA: Americans are required health insurance or there is a tax penalty. This was used to attract healthy individuals to the marketplace to balance the risk pools and pay for sicker individuals.
    • AHCA: The AHCA repeals this provision and applies it retroactively beginning in 2016.
  • Subsidies
    • ACA: Individuals who do not have insurance through employers will receive premium tax credits to assist with purchasing health insurance through the exchanges. The subsidies are available to people with incomes up to 400% of the poverty line. There are also cost-sharing subsidies for low income people.
    • AHCA: The AHCA repeals the subsidies. The AHCA replaces these with refundable, age based tax credits. The credits start at $2,000 a year for people under 30, with a maximum of $4,000 a year for people over 60.
  • Medicare “Doughnut Hole”
    • ACA: Closes the gap in Medicare Part D prescription drug coverage by 2020.
    • AHCA: No changes
  • Essential Health Benefits (EHBs)
    • ACA: All health plans in individual and small group markets must cover 10 categorical benefits.
    • AHCA: States would be able to get waivers to set their own minimum benefits, starting in 2020.
  • Lifetime Limits
    • ACA: Health insurance companies can no longer limit how much they will pay in benefits over a customer’s lifetime.
    • AHCA: The AHCA keeps this provision, however since it is tied to EHBs it could prove to be repealed if states waive the EHBs rules.
  • Employer Mandate
    • ACA: Employers with 50 or more full-time employees have to pay penalties if they do not cover their employees, or if their health insurance does not meet affordability standards.
    • AHCA: The AHCA repeals the mandate retroactively starting in 2016.
  • Taxes
    • ACA: The ACA is funded through various taxes including annual fees for health insurers, a 2.3% tax on the sale of medical devices, and a 3.8% tax on net investment income from high income individuals. The ACA also created a 40% “Cadillac tax” on high-cost employer health insurance plans.
    • AHCA: The AHCA would repeal all the taxes.
  • Medicaid Expansion
    • ACA: States that expanded their Medicaid programs to cover additional low income residents were given additional federal matching funds.
    • AHCA: The AHCA would end the Medicaid expansion in 2020. States would still be able to expand through 2019 and receive matching funds.
  • Age Rating
    • ACA: Insurers in the individual and small group market can only charge premiums three times as high for older customers as for young adults.
    • AHCA: The AHCA will relax this rule, allowing insurers to charge up to 5 times for older customers as for young adults.
  • Preventive Care
    • ACA: Requires most to cover preventive services without charging patients out-of-pocket payments like co-payments or co-insurance.
    • AHCA: No change
  • Medicare Payment Cuts
    • ACA: Reduces payments to hospitals and providers producing about $800 billion in savings over 10 years to pay for the ACA.
    • AHCA: No changes, does not affect the payment cuts.

US Surgeon General Dismissed

President asked the U.S. Surgeon General Vivek Murthy, appointed by former President Obama, to resign. On Friday, Rear Adm. Sylvia Trent-Adams, who previously served as deputy Surgeon General, was named Acting Surgeon General. Trent-Adams is a former nurse officer in the Army and has also served as a research nurse at the University of Maryland. She joined the Commissioned Corps of the Public Health Service in 1992 and served as the deputy associate administrator for the HIV/AIDS bureau of the Health Resources and Services Administration (HRSA) before joining the surgeon general’s office. Dr. Murthy had served as surgeon general since 2014. During this time, he released the office’s first comprehensive report on addiction in America.  

Opioid Assistance to States

The U.S. Department of Health and Human Services (HHS) announced last week that the first round of grants to assist states and territories in combating the opioid epidemic will be released. The grants to all 50 states will total $485 million, and will be administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). The grants are a product of the 21st Century Cures Act, and will be used to prevent opioid abuse and provide treatment to those affected by addiction.  

The Centers for Disease Control and Prevention (CDC) announced plans to launch an ad campaign to raise awareness about the danger of opioid addiction. The goal of the campaign is to make doctors and patients more knowledgeable about the opioid crisis, and to help them understand the risks associated with opioids so they can be discussed before any problems arise. At the Food and Drug Administration (FDA), the agency announced that it will convene stakeholders for a public workshop in May on how to best train health care professionals about pain management and the safe prescribing of opioids.  

Federal Hiring Freeze Thawing

White House announced that it will lift President Trump’s federal hiring freeze. The announcement came as a part of guidance ordering federal departments and agencies to submit restructuring plans to the Office of Management and Budget (OMB). Agencies are directed to begin taking actions to reduce the size of their workforce over the long term, in accordance with the President’s budget outline (which includes cuts to the National Institutes of Health (NIH). Agencies were instructed to develop a plan to maximize employee performance by June 30.

Medicare Proposes 2.9 Percent Increase in Hospital Payments The Trump administration on opened a debate about how to ease the regulatory burden on hospitals as it unveiled a proposed Medicare payment rule covering services provided to admitted patients. Payments for so-called inpatient hospital care may rise by 2.9 percent in fiscal 2018, the agency said.   The draft rule covers one of the largest annual federal expenses. Medicare, which serves senior citizens and people with disabilities, paid about $112 billion for inpatient care in 2015, according to the Medicare Payment Advisory Commission. Outpatient care cost the program another $58 billion that year.  

Enrollment Rule for Exchange Plans Major Benefit for Insurers

The Trump administration announced in a new rule it would cut in half the number of days that consumers are allowed to shop for 2018 medical coverage on health exchanges, siding with insurers over groups such as the American Cancer Society.  

The 2018 open enrollment period will be reduced to run from Nov. 1, 2017, to Dec. 15, 2017, a shift from an earlier cutoff date of Jan. 31, 2018, the Centers for Medicare and Medicaid Services said in its final published rule.  

The earlier deadline will limit the number of people who can purchase insurance after learning they have a health condition that requires medical care, blocking such signups in late December and January, CMS said. Thus, this move will help improve the so-called risk pool for insurers, or the balance of their healthier customers to those in need of costly medical services, the agency said.  

The new rule also includes steps to limit what CMS calls “potential misuse and abuse” of special enrollment periods, which are meant to help people who need health insurance due to a major life change after the regular window closes. The rule will allow insurers to require customers to pay past due premiums before enrolling into another of their plans in a subsequent year. CMS said this will stop people from “gaming” the insurance system and encourage them to maintain coverage.  

Supreme Court Justice Confirmed

Judge Neil Gorsuch joined the Supreme Court and restore its previous conservative ideological tilt, emerging from an epic 14-month partisan battle over a vacancy that reshaped the Senate’s confirmation process for high court nominees.   The Senate on Friday confirmed, 54-45, the 49-year-old federal appeals court judge from Colorado as the next Supreme Court justice on a mostly party-line vote. He will be sworn in Monday, the court said.   Gorsuch will fill the vacancy created by the death of Antonin Scalia in February 2016.  

March 2017

Affordable Care Act Repeal Fails to Garner Vote House Republicans have ended consideration of their bill to repeal and replace the Affordable Care Act (ACA) because it lacked enough support for passage. The House floor vote on the American Health Care Act (H.R. 1628) was cancelled only shortly before it was scheduled to take place on Friday afternoon. Republicans had intended to repeal President Obama’s signature accomplishment on the seventh anniversary of its signing into law. GOP leadership had struggled to garner the votes necessary to pass the proposal since unveiling the plan. Negotiations attempted to appease two factions of the Republican Party: the conservative Freedom Caucus, which wanted to address the cost of health insurance through complete repeal of the ACA, and more moderate members, who were concerned about an increase in the uninsured rate and constituents loosing health care coverage. The Congressional Budget Office (CBO) found that recent changes to AHCA, like immediate repeal of Obamacare taxes and providing states the options of receiving Medicaid block grants and using work requirements in Medicaid, would result in less deficit reduction than the original AHCA draft but would lead to the same levels of coverage losses and premium increases. Other late-breaking revisions to the bill include the elimination of essential health benefit requirements and the addition of $15 billion to the Patient and State Stability Fund, paid for by keeping the ACA’s Medicare tax on high earners for an additional six years. The Freedom Caucus pushed for the elimination of the insurer ban from denying coverage to people with preexisting conditions, which would have resulted in a reduction in premium costs. The White House, however, was not willing to negotiate on the issue of preexisting conditions. In an attempt to pressure conservative Republicans to support the bill, President Trump issued an ultimatum, saying that he would leave the ACA in place unless lawmakers passed the White House backed legislation to repeal and replace the law. CMS Allocates Funds to Help Small Practices Succeed in QPP The Centers for Medicare & Medicaid Services (CMS) on February 17 granted approximately $20 million to 11 community-based organizations (CBOs) for the first year of a five-year program to educate and provide training on the Quality Payment Program (QPP) to health care practitioners in individual or small group practices with up to 15 clinicians. CMS will invest up to an additional $80 million over the next four years. CBOs will provide these educational resources free of charge to numerous small practices, particularly those health care professionals who practice in historically disadvantaged and under-resourced areas, including rural areas, health professional shortage areas, and medically underserved areas. The CBOs will help practitioners successfully participate in the QPP by providing assistance with tasks such as selecting and reporting quality measures. A list of the 11 CBOs is included in the CMS press release. To further assist practitioners in the transition to QPP, CMS has introduced a helpline that can be accessed at 866-288-8292. Register Now for CMS Call on Global Codes Postoperative Care Data Reporting The American College of Osteopathic Surgeons (ACOS) encourages members who are subject to the Centers for Medicare & Medicaid Services (CMS) reporting requirements for 10- and 90-day global services to participate in a CMS teleconference, 1:30−3:00 pm EST, Tuesday, April 25. This call will provide information regarding the new reporting requirements, along with reporting resources and tools. The rule takes effect July 1 and applies to practitioners who furnish 10- and 90-day global services on a CMS list of 293 codes and who are in practices with 10 or more other practitioners in any of nine select states—Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. These practitioners will be required to report Current Procedural Terminology (CPT) code 99024 for each postoperative visit related to the specified codes for services that they provide to a Medicare beneficiary. The call will include a question-and-answer period. Coders, billers, and practice managers in the nine select states are encouraged to participate as well. Details about the call, including registration information, are posted on the CMS website. Insurance Reforms Move Ahead The House passed two bills that were intended to be a part of the GOP health care reform plan to enhance the American Health Care Act (AHCA). H.R. 372, the Competitive Health Insurance Reform Act, would end the exemption for health insurers from federal antitrust laws, and was passed by a vote of 416-7. The 1945 McCarran-Ferguson Act exempted insurers from federal antitrust laws to the extent it is regulated by a state. Republicans supported the bill as a means to increase competition in the health insurance market, while Democrats are in favor of enforcing antitrust regulations should insurers collude to raise rates or engage in other anti-competitive practices. The House also passed legislation that would remove some of the regulations on small businesses providing health insurance to their employees through association health plans (AHPs). Trumps First Speech to Congress In his first address to a joint session of Congress, the President voiced support for both the use of tax credits and an expansion of health savings accounts (HSAs) in repealing and replacing the Affordable Care Act (ACA). He also backed maintaining the law’s provision that requires insurance carriers to cover individuals with pre-existing conditions, as well as the provision of additional state flexibility to administer the Medicaid program. The President also mentioned support for medical liability reform, addressing the rising cost of prescription drugs, and expanding the ability to sell health insurance across state linesPresident Trump had again suggested that his Administration may have plans to release their own plan to replace the 2010 health care law, separate from the work being done by congressional GOP leadership to overhaul the health care system. Trumps Plan for Drug Pricing While the GOP’s American Health Care Act (AHCA) does not contain any provisions that would address drug pricing, Rep. Elijah Cummings (D-Md.) said that the President is willing to work with Democrats on the issue. President Trump and Rep. Cummings met on the subject, and the President signaled he was open to granting the government more power to negotiate drug prices. Congressional Republicans have been historically opposed to such a policy. Rep. Cummings intends to introduce legislation on the subject in the coming weeks with Rep. Peter Welch (D-Vt.). Continuing with Phase Two and Three Phase one of GOP health care law repeal and replacement action has been deferred, but phases two and three continue. The administration can change regulatory requirements of the law and Congress can begin work on new legislative measures on health coverage options. Health and Human Services Secretary Tom Price was asked in a hearing last week about his ability to make regulatory changes to lower the cost of insurance coverage. Price responded: “Fourteen hundred and forty-two times the ACA said, the secretary shall or the secretary may.” Price precisely counted the opportunities for regulatory adjustments to the law. Phase three of the GOP plan for health care law action calls for new legislation on health insurance market changes and proposals to entice lower health care costs. However, the new legislation is not covered by budgetary reconciliation rule and will require some Democratic support in the Senate along with unified Republican support in the House. Another test of phase three legislation begins this week with a planned vote on a bill addressing employer-sponsored health plan use of stop-loss coverage (HR 1304, view bill text). Self-insured health plans may purchase stop-loss coverage to cover costs after claims reach a specified level. The measure seeks to protect the special coverage by omitting stop-loss insurance from health plan regulations. More than half of all individuals with health insurance coverage in the U.S. are covered through employer plans.

March 2017

leg IPAB Repeal Messaging Points Experts say that in 2017, Medicare spending could finally trigger the Independent Payment Advisory Board, or IPAB, to go into effect – posing an imminent threat to healthcare access for the nation’s 55 million Medicare beneficiaries.

  • Established by the Affordable Care Act as a tool to help control Medicare spending, IPAB is to be a board of presidential appointees charged with making recommendations for cutting Medicare expenditures once the program’s spending growth hits an arbitrary level.
    • While spending growth did not trigger IPAB to go into effect as many anticipated in 2016, nearly all experts – including Medicare’s trustees – agree it will be triggered in 2017.
    • As designed, IPAB would usurp congressional authority over the Medicare program while granting unprecedented powers with virtually no oversight.
      • IPAB is allowed to propose virtually unlimited changes to Medicare, which will automatically take effect unless Congress acts.
    • IPAB would likely make significant, arbitrary cuts in Medicare payments for healthcare providers.
      • These cuts would have a potentially devastating impact on Medicare patients – affecting access to care as well as to innovative therapies and new care approaches.
  • As designed, IPAB is a blunt instrument that focuses on reducing what Medicare pays for healthcare services rather than on what’s in the best interest of patients.
    • It threatens to shift more healthcare costs to consumers and employers.
    • Physicians are working hard to keep up with new quality improvement and reporting requirements, in exchange for Medicare incentives that IPAB could cancel out.
    • The cuts could make it more difficult for physicians to see new Medicare patients, or undermine the financial viability of physicians with a large Medicare caseload.

Regardless of what Congress and the administration decide regarding the Affordable Care Act, diverse healthcare stakeholders are urging Congress to repeal IPAB.

  • Over 650 organizations from throughout the country, representing nearly every healthcare stakeholder, have aligned to urge repeal of IPAB. They agree that, while greater efficiency of the Medicare system is necessary, IPAB is not the solution.
    • Representing patients, physicians, employers, nonprofits, hospitals, insurers, veterans, and individuals with disabilities, these organizations are calling for Congress to treat this issue with urgency, repealing IPAB before it is triggered into action in 2017.
  • Also at issue is the fact that there have been no presidential appointees named to IPAB, which would require the U.S. Secretary of Health and Human Services to make recommendations on Medicare cuts, which would automatically go into effect unless Congress overrides them with a supermajority vote.
    • This places an unprecedented level of decision-making power in the hands of one individual.
  • Two bills to eliminate IPAB have been introduced in the U.S. Senate, one by Senator John Cornyn (R-TX) and another by Senator Ron Wyden (D-OR). An IPAB repeal resolution has been introduced in the U.S. House by Congressmen Phil Roe (R-TN) and Raul Ruiz (D-CA), with a full repeal bill expected imminently. It is essential that we urge Democratic and Republican Senators to cosponsor the Wyden and Cornyn repeal bills.

Medicare beneficiaries need to make their voices heard, because repealing IPAB ensures seniors and their doctors maintain control over their treatment and other healthcare decisions.

  • There are preferable alternatives to making Medicare more quality-driven and cost-efficient, including evidence-based best practices, implementation of continuous quality improvement measures, innovations in medicines and delivery systems, and widespread use of electronic health records. These are some of the steps that can improve care to seniors while containing costs over the long term.
  • A national survey conducted by Morning Consult finds that the majority of registered voters – 84 percent – trust their doctors most when it comes to medical treatment decisions.
    • 75 percent of respondents – and nine of every 10 seniors – agree with the statement, “The government needs to find ways to keep the promise and integrity of Medicare without cuts to the program.”
    • When asked about different approaches to address Medicare’s finances, 75 percent opposed limiting access to treatments and medications.

More information about this effort can be found at the Protect My Doctor and Me website at Additionally, you can follow the conversation on Twitter @MyDrAndMe.

leg IPAB Repeal Newsletter Article WE’RE AT THE FOREFRONT OF THE EFFORT TO REPEAL IPAB AND PRESERVE PATIENT ACCESS TO CARE Recently, AOAO joined more than 650 organizations, representing healthcare stakeholders from all 50 states, to urge Congress to repeal the Independent Payment Advisory Board (IPAB). Established by the Affordable Care Act as a tool to reduce Medicare spending, IPAB is a board of presidential appointees charged with making recommendations for cutting Medicare expenditures once the program’s spending growth reaches an arbitrary level. Experts say that this threshold will be met in 2017 and IPAB will go into effect – posing an imminent threat to healthcare access for the nation’s 55 million Medicare beneficiaries. IPAB-recommended cuts become law unless they are overturned by a supermajority in Congress. As designed, IPAB is a blunt instrument that will not add value to the Medicare program, but rather will focus on reducing what Medicare pays for healthcare services and treatments. Providers are already reimbursed less by Medicare than they are by private health insurance, and IPAB could drive these payments down further, affecting the ability of physicians to treat a growing population of Medicare beneficiaries. IPAB also threats to shift more health costs to consumers and employers. There is wide bipartisan support in Congress to eliminate IPAB, but repeal needs to take place immediately before it can be triggered into action. Two bills to eliminate IPAB have been introduced in the U.S. Senate, one by Senator John Cornyn (R-TX) and another by Senator Ron Wyden (D-OR). An IPAB repeal resolution has been introduced in the U.S. House by Congressmen Phil Roe (R-TN) and Raul Ruiz (D-CA), with a full repeal bill expected imminently. It is essential that we urge Democratic and Republican Senators to cosponsor the Wyden and Cornyn repeal bills. We all agree that Congress must pursue alternative approaches that achieve cost-efficiency while improving care quality. These efforts must be evidence-based and made in the best interest of the doctor-patient relationship. IPAB will neither strengthen Medicare nor meet the needs of the more than 55 million Americans who depend on the program for their health and well-being. It must be repealed. More information can be found at the Protect My Doctor and Me website: Also follow the discussion on Twitter at @MyDrAndMe

January 2017

CMS Proposes Rule for the Establishment of Special Payment Provisions and Requirements for Qualified Practitioners and Qualified Suppliers of Prosthetics and Custom Fabricated Orthotics

CMS proposed rule would implement statutory requirements and specify: the qualifications needed for qualified practitioners to furnish and fabricate prosthetics and custom-fabricated orthotics, and for qualified suppliers to fabricate prosthetics and custom-fabricated orthotics; accreditation requirements that qualified suppliers must meet in order to bill for prosthetics and custom fabricated orthotics; requirements that an organization must meet in order to accredit qualified suppliers to bill for prosthetics and custom-fabricated orthotics; and a timeframe by which qualified practitioners and qualified suppliers must meet the applicable licensure, certification, and accreditation requirements. This rule would also remove the exemption from quality standards and accreditation that is currently in place in accordance with section 1834(a)(20) of the Act for certain practitioners and suppliers who furnish or fabricate prosthetics and custom fabricated orthotics. In addition, this rule also includes authority for the Centers for Medicare & Medicaid Services (CMS) to revoke the Medicare enrollment of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers that submit claims for items that do not meet the requirements of the statute and this proposed rule. A copy of the proposed rule is available here. The Department is accepting comments through March 13, 2017.

EHR Incentive Programs: New Attestation Resources

The Electronic Health Record (EHR) Incentive Programs attestation system is open through February 28. Providers must attest by the deadline to avoid a 2018 payment adjustment. CMS released two attestation worksheets for eligible professionals and eligible hospitals and critical access hospitals. Visit the 2016 Program Requirements webpage for more information.

2017 Medicare Payment Penalties in Effect as of January 1

The Centers for Medicare & Medicaid Services (CMS) released a fact sheet in late December 2016 regarding penalties that are being imposed in 2017 through the Electronic Health Record Incentive Program, also known as meaningful use. Surgeons and other eligible professionals (EPs) who did not meet meaningful use reporting requirements in 2015 are facing a 3 percent Medicare payment penalty in 2017. According to CMS, approximately 171,000 EPs will experience the negative adjustment. To avoid a penalty in 2018, surgeons may attest to 2016 meaningful use through February 28, 2017. More information about attestation is available through the CMS Registration and Attestation System.

CMS Accepting Applications for CPIA Study

The Centers for Medicare & Medicaid Services (CMS) is conducting a Clinical Practice Improvement Activity (CPIA) study to examine clinical workflows and data collection methods that use different submission systems. The goal is to gain an understanding of the challenges that clinicians encounter when collecting and reporting CPIA data. Clinicians and group practices that are eligible for the Merit-based Incentive Payment System (MIPS) and that successfully participate in the study will receive full credit for the Improvement Activities performance category of MIPS. Participants in the 2017 study must meet the following requirements throughout 2017: • Complete at least three survey questionnaires • Participate in at least three focus groups • Submit at least three clinician quality performance measures to CMS For more information and to apply to participate in the study, visit the CMS website. CMS is accepting a limited number of participants into the study, so applications should be completed as early as possible. Completed applications should be submitted to by January 31.

CMS Releases 2017 QPP Quality Measure Benchmarks

If a physician or practice plans to participate in 2017 Quality Payment Program (QPP) (aka MIPS) with the goal of receiving a bonus in 2019 it is highly recommended that they review the recently released 2017 QPP Measure Benchmark information. The 2017 quality benchmark information does not apply to physicians who only plan to participate in 2017 to avoid a 2019 penalty (submit one measure, one time in 2017). The 2017 CMS QPP benchmark information was released late last week and posted to the CMS QPP website. The benchmark calculations for the 2017 performance year use data that was submitted for PQRS in 2015 by clinicians that were a Quality Payment Program provider type eligible for MIPS and were not newly enrolled in 2015, or groups with at least 1 such clinician. When a clinician submits measures for the QPP Quality Performance Category, each measure is assessed against its benchmarks to determine how many points the measure earns. A clinician can receive anywhere from 3 to 10 points for each measure (not including any bonus points). Benchmarks are specific to the type of submission mechanism: EHRs, QCDRs/Registries, CAHPS and claims. For CG-CAHPS, the benchmarks are based on two sets of data, 2015 PQRS CAHPS and 2015 ACO CAHPS data. Submissions via CMS Web Interface will use benchmarks from the Shared Savings Programs. Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see Table 1). Clinicians who receive a score in the first or second decile will receive 3 points. Clinicians who are in the 3rd decile will receive somewhere between 3 and 3.9 points depending on their exact position in the decile, and clinicians in higher deciles will receive a corresponding number of points. For example, if a clinician submits data showing 83% on the measure, and the 5th decile begins at 72% and the 6th decile begins at 85%, then the clinician will receive between 5 and 5.9 points because 83% is in the 5th decile. For measures where a positive performance is seen in a lower score, the scores are reversed in the benchmark deciles.

CMS Releases Patient Facing Encounter Codes

CMS released and posted to the QPP website the list of patient-facing encounter codes. The list is used to determine the non-patient facing status of MIPS eligible clinicians. Given the flexibility in program requirements for non-patient facing clinicians, the encounter codes are critical for CMS to identify MIPS eligible clinicians. A non-patient facing MIPS eligible clinician is: • An individual MIPS eligible clinician that bills 100 or fewer patient-facing encounters (including Medicare telehealth services defined in section 1834(m) of the Act) during the non-patient facing determination period, and • A group provided that more than 75 percent of the clinicians billing under the group’s TIN meet the definition of a non-patient facing individual MIPS eligible clinician during the non-patient facing determination period. The list of patient-facing encounter codes are categorized into three overarching groups of codes (Evaluation and Management Codes; Surgical and Procedural Codes, and Visit Codes). The utilization of Evaluation and Management Codes, Surgical and Procedural Codes, and Visit Codes classifies MIPS eligible clinicians as non-patient facing and patient-facing.

Health Industry Calls for Stabilization

Executives from major insurance and pharmaceutical companies and hospitals are pressing the incoming Trump administration to shore up the health insurance marketplaces. Companies like Aetna, Blue Cross Blue Shield of Tennessee, Johnson and Johnson and Novartis, who are members of the Healthcare Leadership Council, outlined policy proposals that the group agrees “should be taken immediately to stabilize the health insurance marketplace,” according to a release. They asked Congress to pour more federal money toward the sickest consumers, to provide refundable tax credits to help people afford coverage, to repeal the health law’s health insurance tax and to reduce federal oversight of the insurance marketplaces. The companies’ requests come just as Republicans on Capitol Hill and in the administration are ramping up for an aggressive effort to repeal the law. Vice President-elect Mike Pence met with Republicans to discuss the administration’s plans to repeal parts of the law through executive action, and to press lawmakers to get a repeal bill to the new president’s desk before Feb. 20, according to members who attended the meeting. Lawmakers have suggested they will include a transition period in their repeal plans, in order to ensure people who currently have coverage under the health law are not kicked off their plans immediately. That also will give Republicans some time to come up with a replacement plan. The threat of repeal has worried nearly every sector of the health care industry. Hospitals argue they stand to lose hundreds of billions of dollars if the law is annulled. Insurers have long decried the current marketplaces as unstable. They caution that repeal and replacement efforts must be measured and deliberate to minimize disruption.

Health Law Repeal Could Spur Job Losses, Report Says

Repealing provisions of the health care law, such as the Medicaid expansion and the tax subsidies that help those in lower income brackets purchase individual plans, could result in millions of jobs lost over the next few years. The analysis, by the Commonwealth Fund and researchers at George Washington University’s Milken Institute School of Public Health, predicts a $140 billion federal cut in health spending in 2019, resulting in 2.6 million jobs lost. The authors acknowledge that they cannot yet incorporate other policies, such as an anticipated Republican plan to replace the health law into their analysis. The health care sector makes up about one-fifth of the economy, but the researchers say the jobs will not just be lost in health and insurance: the loss of federal funding could have a cascading impact on the construction, real estate and retail industries as well, including in states that have not pursued a Medicaid expansion. “Because economic benefits and losses flow across state lines, even states that did not expand Medicaid would experience losses if Medicaid expansions were canceled,” the report says. President-elect Donald Trump and has proposed Medicaid block grants, and the researchers note that if the grant levels incorporate the expansion, that could help blunt the economic impact. Overall, by 2023, the researchers predict $2.6 trillion could be lost in business output and $48 billion lost for state treasuries due to revenue decreases and the increasing cost of uncompensated care.

December 2016

Senate Committee on Finance Issues Final Report on Concurrent Surgery The United States Senate Committee on Finance began an investigation of concurrent surgery and released its findings in a report. The report is available here.   In early 2016, the Committee sent a letter to 20 teaching hospitals querying them about the practice in their institutions. The letter generated strong interest from hospitals, individual physicians, patient advocates, and others who reached out to the Committee to share their experiences, insights, and knowledge about these issues. Additionally, Committee staff examined guidance issued by the Centers for Medicare & Medicaid Services (CMS), within the Department of Health and Human Services (HHS), and the American College of Surgeons (ACS), policies and other information provided to the. The report is a summary of the Committee’s staff’s findings to date and an overview of key issues and areas of Congressional concern.   The report outlined two areas that troubled the Committee most, patient safety and improper payments. The patient safety concerns focused on whether patients are giving consent to have these types of surgeries performed and whether they are safe to perform. The Committee is asking for further guidance and an examination on how best to proceed from CMS and the ACS. The Committee is asking for particular procedures that could be allowed to have concurrent surgeries performed and to further define the “critical parts” of the surgery. The second area of concern is the improper payments from Medicare and Medicaid. CMS has not taken any steps to determine whether the existing billing requirements applicable to teaching physicians in hospitals are or are not being followed despite a history of problems in this area. Second, CMS’s billing requirements are applicable only to teaching physicians operating in hospitals. There are no billing requirements in place that would prevent a surgeon from billing for two or more concurrent surgeries in hospitals outside of a teaching scenario, such as when a physician is assisted by a technician, or in nonhospital settings, such as in ambulatory surgery centers. The Committee is asking for further investigations into billing practices of teaching physicians and whether additional similar measures are needed for other surgical scenarios and facilities.   FIRST Trial: Residents with More Patient Responsibility Prefer Flexible Work Hours U.S. general surgery residents prefer work hour policies that allow them the flexibility to put in more time in the hospital when needed to provide patient care over more restrictive work schedules, according to results from a national survey conducted as part of the Flexibility in Duty Hour Requirements for Surgical Trainees (FIRST) Trial. The new analysis—which is derived from a survey of more than 95 percent of the 3,700 surgeons in training who participated in the FIRST Trial—found that 86 percent of surgical residents preferred flexible duty-hour policies over regulated duty hours or had no preference.   The FIRST Trial was the first national randomized trial to compare standard surgical resident duty-hour requirements with more flexible policies. During the FIRST Trial, 59 general surgery residency programs adhered to standard duty hour policies, which the Accreditation Council for Graduate Medical Education (ACGME) established in 2003 and 2011. The other 58 programs tested a flexible policy that waived certain ACGME rules on maximum shift lengths and mandatory time off between shifts to allow the residents some flexibility.   Findings from the FIRST Trial published earlier this year in the New England Journal of Medicine demonstrated that easing current restrictions on surgical residents’ schedules to allow for some flexibility did not have an adverse effect on general surgery patient outcomes or on overall resident well-being. In fact, residents in the flexible arm of the study noted several benefits with respect to patient care, continuity of care, and resident training.   MedPAC Meets to Discuss Provider Consolidation, Open Payments   During the meeting in Washington, DC, the commission reviewed the role of CMS in provider consolidation and the implications of different types of consolidation for the Medicare program and private payors. MedPAC staff indicated that vertical financial integration, through which hospital systems acquire physician practices, has caused an increase in Medicare spending due to the higher costs associated with providing services typically furnished in physician offices in hospital outpatient settings. Commissioners reiterated their standing recommendation to limit Medicare facility fees and equalize rates for certain services across all sites of care.   MedPAC commissioners also discussed findings from the Open Payments program, through which CMS collects data from drug and device manufacturers and group purchasing organizations (GPOs) on their financial relationships with physicians and teaching hospitals. MedPAC staff provided an analysis of Open Payments data that CMS released from August 2013 to December 2015. In 2015, manufacturers and GPOs made nearly $7.5 billion in payments for research, royalties, consulting, promotional speeches, and other activities to more than 610,000 physicians and 1,100 teaching hospitals. Open Payments data suggested that these payments are skewed toward the top 5 percent of physicians, who accounted for 86 percent of all general payments made by manufacturers and GPOs. MedPAC recommended that research be conducted to examine the relationship between payments from manufacturers and physicians’ use of certain drugs and devices.   Health Policy Issues in the 115th Congress:     A quick look at major health issues facing the Congress.  FDA User Fees   The issue: Congress in 1992 enacted the prescription drug user fee system. Under the program, the pharmaceutical industry and the Food and Drug Administration negotiate an agreement which sets a certain amount that pharmaceutical companies pay each year, known as a user fee, to fund certain initiatives at the agency. That agreement typically is reauthorized every five years and has grown to include the medical device and generic drug industries, among others. User fees now account for almost half of the FDA’s total budget. Next year, Congress will be tasked with reauthorizing the agreements before the current legislation expires at the end of September 2017.   What to expect: House Energy and Commerce Chairman Fred Upton hopes that his legacy legislation, a package of biomedical innovation bills known as 21st Century Cures, will be signed into law in 2016. If the Michigan Republican is unable to make that happen, many of the provisions included in that package are expected to be considered for possible inclusion in the pending user fee reauthorization. The Cures bill included several changes to the pre-market review process for drugs and medical devices. Those measures have bipartisan support and could be included in the user fee reauthorizations next year.   Another issue that potentially could be addressed in next year’s legislation is the rising cost of prescription drugs. The issue was discussed widely on the presidential campaign trail by candidates from both parties and the controversy grew in recent months after Mylan N.V. increased the cost of its EpiPen device, which provides emergency medication for severe allergic reactions. Health Care Law The issue: Republicans are likely to make an effort to repeal President Barack Obama’s signature domestic achievement. The marketplace coverage created by the law already was facing mounting challenges. Premiums for people who buy their health insurance on are ratcheting up by an average 25 percent for benchmark plans. Some insurance companies, citing financial losses, are backing out of the marketplaces. Some are even going bankrupt. However, the law has provided coverage through the exchanges, Medicaid and other programs to roughly 20 million people, according to the Obama administration.   What to expect: The politics surrounding the 2010 health law run deep. President-elect Donald J. Trump earlier this month called for Republicans to act and pledged to call a “special session” to push repeal. If Republicans pass a budget resolution, they can use special procedures to repeal parts of the law through the so-called reconciliation process, which only requires 51 Senate votes rather than 60. Earlier this year, Republicans used reconciliation to clear a measure that would have removed the penalties used to enforce the mandates that most individuals have health coverage and large employers offer it to their workers. It also would have repealed in 2018 the law’s Medicaid expansion and its subsidies to help low- and middle-income individuals buy health coverage through the new insurance exchanges. Obama vetoed it. Children’s Health Insurance The issue: Funding for the popular Children’s Health Insurance Program will expire at the end of September 2017, making a reauthorization bill a must-pass agenda item for the 115th Congress. Lawmakers could pass a simple two-year extension, although advocates and Democrats would prefer a longer approval for the bipartisan program. That will complicate the debate: the program’s entire legislative authority will run out in 2019, as will requirements that prevent states from making it harder for people to enroll in the program. The levels at which it is funded will also be a hot-button issue because the 2010 health law provided states with a 23 percentage point boost. Some fiscal conservatives would like to lower spending, but states that rely on the funds will push to keep them. As they have in years past, advocates are pushing for Congress to extend that funding in the spring to give state legislatures that adjourn early in the year time to set their health budgets.   What to expect: The CHIP program is extremely popular politically, but that hasn’t stopped it from becoming controversial in recent years. Congress may try to begin debate on the program early in the year in an effort to help state officials plan ahead. But the fight is likely to be partisan. In 2015, the last time the program needed to be authorized, Republicans sought a reduction in the funding levels and a repeal of the provisions related to state eligibility requirements. Democrats, meanwhile, held hostage a separate bipartisan measure on Medicare reimbursements in an unsuccessful attempt to force Republicans to fund the program for four years instead of two. Staffing, IT Systems Top Concerns for Medicaid Directors:     A majority of the country’s Medicaid directors said their biggest challenges are related to staffing and technology infrastructure, according to a survey by an advocacy group for the officials. It is a shift from the past several years, when directors were more likely to cite the implementation of the 2010 health overhaul a top challenge.   The results also underscore other ongoing changes in the Medicaid program, which has grown to cover 73.1 million Americans. More Medicaid directors said their priority is so-called payment reform, an industry-wide focus on transitioning health care away from fee-for-service payments, than any other topic. Directors also highlighted a new focus on IT systems and on behavioral health. About half of the directors, meanwhile, cited their administrative budget as a key challenge. Seniors Opt Out of Full Coverage, Lower Medicare Plans’ Profits:   Medicare may be shortchanging insurers because its calculations ignore the growing number of wealthy and working senior citizens who chose not to fully enroll in the giant health program. They estimated that insurers would gain $20 billion over a decade if Medicare rules were to better reflect the number of people opting out.   MedPAC is working on its 2017 suggestions to Congress regarding the continual financial battles between the insurance industry and Medicare. MedPAC also revisited concerns that some insurers may be identifying customers in their Medicare Advantage plans as sicker than they are to secure extra pay. Medicare sets payments for the Advantage plans by looking at how much the traditional fee-for-service program spends. These calculations factor in spending in both major components of Medicare: the Part A section that covers hospital care and Part B that covers more routine care such as visits to doctors.   A small but growing number of people opt out of Medicare Part B while remaining in Part A, MedPAC staff said Friday. This group grew to 12.4 percent of Medicare’s population in 2015 from 10.2 percent in 2009. People who opt out of Part B also appear to be in better general health, reducing the hospital bills for Part A as well. This may cause further distortion in setting reimbursements for Advantage plans. Sticker shock about Medicare Part B premiums appears to be driving the decision to opt out in many cases. Some people do decline Part B because they continue working and thus have health insurance provided by their insurers. More often, though, people might make this call because they cannot afford Part B premiums or decide that that are a bad deal. CMS Timelime for Off-Campus Doctor Pay Rule Raises Alarms:     The Centers for Medicare and Medicaid Services said it will create special rates for newer hospital-owned practices by Jan. 1 through an administrative fast-track proposal, known as an interim final rule. This is intended to help hospitals determine how to bill for these kinds of services, which they previously billed under the more lucrative hospital outpatient rule. In many cases, the pay for newer hospital services would be set under these transition rates at about half of the former outpatient reimbursement, CMS said. CMS attached the interim rule to the final rule on 2017 outpatient payment.   The budget law mandate does not apply to hospital-owned practices already in operation at the time the measure took effect in November 2015. They can continue to bill at the higher outpatient rates rather than the lower reimbursements set in the physician fee rule.