July 2017

Better Care Reconciliation Act Released

The bill would provide $50 billion over four years to stabilize the insurance market. This funding would be in addition to cost-sharing subsidy payments, which would be extended through 2019. It also includes $62 billion over eight years for a state innovation fund, which could be used for coverage of high-risk patients, reinsurance, or other similar purposes.  The bill would retroactively eliminate the individual and employer mandates to 2016. It repeals taxes on health insurers, medical devices, prescription drugs, and indoor tanning. It also eliminates the Affordable Care Act’s (ACA) investment income tax and the Medicare surtax. The Cadillac tax on high cost health plans would be delayed from 2020 to 2026.  

Unlike the House-passed AHCA, the bill does not contain the 30% surcharge for lack of continuous coverage. Like the House bill, the Senate bill includes a provision to give states the flexibility to alter their health markets, which may include waiving essential health benefit requirements. However, unlike the House bill, the Senate uses a waiver process that is already in place – section 1332 waivers, with additional changes to the current waiver program. Like the House bill, it also changes insurer age rating to allow older adults to be charged as would be provide much as five times younger people. Premium subsidies in the individual market making up to 350 percent of the poverty level beginning in 2020. The current cutoff is 400 percent of the poverty level. The insurance subsidy system would also be plan rather than less generous than under current law, and based on 58% of actuarial value (the cost of a low-level bronze plan (which the Centers for Medicare and Medicaid Services has estimated to be near 70% actuarial value).  

The bill includes a provision to tighten subsidy eligibility on the basis of immigration status. Medicaid expansion would be phased from 2021 until 2024. Unlike the House bill, Federal spending on Medicaid would be capped using a more stringent measure of inflation (CPI-U), rather than the medical inflation rate (CPI-M) used in AHCA, beginning in 2025. The bill includes an additional $2 billion in fiscal year (FY) 2018 to address the opioid epidemic and (like the House bill) would defund Planned Parenthood for one year.  

The legislation was recently amended with Senator Ted Cruz’s (R-Texas) Consumer Freedom Act, which would allow the sale of plans that don’t comply with the Affordable Care Act’s (ACA) insurance regulations on pre-existing conditions and essential health benefits (EHBs). The revised bill includes an additional $70 billion in new funding over the next seven years aimed at reducing costs for individuals who remain in the regulated-insurance plans. Beginning in 2022, states would begin having to share an increasingly higher portion of this cost. The new BCRA would keep in place several ACA taxes on the high earners, which would result in a revenue stream of nearly $232 billion over the next ten years. The revised measure includes the addition of $45 billion to combat the opioid epidemic. It would also allow individuals to use health savings accounts (HSAs) to pay for insurance premiums. Additionally, individuals would be allowed to purchase high deductible catastrophic coverage plans with federal tax credits. Medicaid payments to hospitals for coverage of uncompensated care would be calculated according to the state’s uninsured population, instead of the state’s Medicaid enrollment, as originally drafted.  

 

2017 Trustees Report Released; IPAB Not Triggered

The 2017 Medicare Trustees Report, which projects the long-term finances of the Medicare program, was released last week. The Board of Trustees finds that Medicare spending will not trigger the Independent Payment Advisory Board (IPAB) until 2021. The Board had previously forecast that the cost-cutting panel would be triggered this year. The 2017 report also indicates that the Medicare trust fund will remain solvent until 2029, a year later than previously predicted, though the reason for the slowdown is unclear.  

GAO: Locations and Types of Graduate Training Were Largely Unchanged, and Federal Efforts May Not Be Sufficient to Meet Needs

The GAO released a report on GME. The report describes (1) changes in number of residents in GME training by location and type of training from academic years 2005 through 2015, (2) federal efforts intended to increase GME training in rural areas, and (3) federal efforts intended to increase GME training in primary care. To determine changes in the locations and types of residents in GME training, GAO analyzed resident data from the accrediting bodies overseeing GME training. To identify and describe relevant federal efforts, GAO also reviewed federal laws, reports, and data, and interviewed agency officials  

Cybersecurity Report Released

The Health Care Industry Cybersecurity Task Force released a report last week asserting that improved cybersecurity protections are needed for medical devices and health information technology. The public-private task force includes representatives from both the U.S. Department of Health and Human Services (HHS) and the U.S. Department of Homeland Security, and was created by the Cybersecurity Act of 2015. The report recommends increased information sharing between the public and private sector on cyber-risks. The Task Force also supports the creation of exceptions to health care anti-fraud laws to allow health care organizations aid physicians in the purchase of cybersecurity software.  

GAO: CMS Should Track MA Dropouts

The Government Accountability Office (GAO) has recommended that the Centers for Medicare and Medicaid Services (CMS) should track whether the Medicare Advantage enrollees who drop out of managed care plans are getting adequate care. The GAO report found that beneficiaries in poorer health are more likely than others enrolled in Medicare Advantage to voluntarily leave their health plans. These plans tended to have lower quality scores, with enrollees more likely to face difficulty in accessing care. The plans were also more likely to be restricted provider network health maintenance organizations. The GAO suggests that CMS take advantage of the opportunity to use disenrollment data to better target oversight and identify problems within the Medicare Advantage program.  

CBO Releases Estimate on BCRA

The Congressional Budget Office (CBO) released an estimate of enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives. The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.  

Trump Nominates New Surgeon General

President Trump has tapped Jerome Adams to be U.S. Surgeon General. Adams is an anesthesiologist and is currently serving as the health commissioner for the state of Indiana, a post he was appointed to in 2014 by now-Vice President Mike Pence. He has previously worked as a staff anesthesiologist and assistant professor of anesthesiology at the Indiana University School of Medicine. If confirmed, Dr. Adams would replace Rear Admiral Sylvia Trent-Adams, the current acting surgeon general, who took over the post after Vivek Murthy was dismissed by President Trump.  

House Passes Medical Malpractice Reform Legislation

The House of Representatives passed legislation to overhaul the medical liability system last week. H.R. 1215, the Protecting Access to Care Act (PACA), was passed by a vote of 218-210, with 19 Republicans crossing the aisle to join all House Democrats to vote against the bill. PACA is considered a part of the GOP’s broader effort to repeal and replace Obamacare.  

The bill would limit damages and lawyers’ fees for cases related to federally subsidized health care. Medical malpractice awards for non-economic damages would be capped at $250,000 under the bill. The bill would also establish a three-year statute of limitations after an injury, or one year after the discovery of an injury. PACA would preempt state laws, except in cases where the state has already specified a shorter time period for the statute of limitations, or a particular amount of damages that can be awarded in a lawsuit. The Congressional Budget Office (CBO) estimates that the bill would reduce the deficit by $50 billion over the next decade.  

It is unclear whether the bill will advance in the Senate, where Democrats are opposed to the liability cap, and some Republicans have voiced concerns about infringing upon states’ rights. More than two-dozen states already have award caps in place. To respond to concerns related to state’ rights, the provisions in the PACA legislation are limited to when a medical liability case involves federal healthcare funds.  

CMS Releases 2018 QPP Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule June 20 that describes changes that would be made to the Quality Payment Program (QPP) in 2018, as required under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015. The QPP provides two tracks for participation: the Merit-based Incentive Payment System (MIPS) or an Advanced Alternative Payment Model (A-APM). Most providers will participate in the MIPS program during the early years of the QPP. The proposed rule alters existing requirements while also introducing new policies that aim to simplify QPP, particularly for small, independent, and rural practices, while maintaining fiscal sustainability and high-quality care within Medicare.   Important provisions of the proposed rule are as follows:

  • CMS proposes to maintain the 2017 transition year weights for the MIPS components—60 percent for Quality, 25 percent for Advancing Care Information (ACI), 15 percent for Improvement Activities, and 0 percent for Cost.
  • CMS proposes to allow MIPS-eligible clinicians to continue participation in the ACI category by using 2014 certified electronic health record technology (CEHRT), thereby providing additional time for practices to move toward use of 2015 CEHRT.
  • CMS proposes to increase the low-volume threshold to exempt providers or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries (from a 2017 low-volume threshold of ≤$30,000 in Part B allowed charges or ≤100 Part B beneficiaries) from having to meet the MIPS participation requirements.

For more information, see the 2018 QPP Proposed Rule and the CMS Fact Sheet.  

June 2017

New Medicare cards offer greater protection to more than 57.7 million Americans The Centers for Medicare & Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. The new cards will use a unique, randomly-assigned number called a Medicare Beneficiary Identifier (MBI), to replace the Social Security-based Health Insurance Claim Number (HICN) currently used on the Medicare card. CMS will begin mailing new cards in April 2018 and will meet the congressional deadline for replacing all Medicare cards by April 2019.   Providers and beneficiaries will both be able to use secure look up tools that will support quick access to MBIs when they need them. There will also be a 21-month transition period where providers will be able to use either the MBI or the HICN further easing the transition.   CMS testified on Tuesday, May 23rd before the U.S. House Committee on Ways & Means Subcommittee on Social Security and U.S. House Committee on Oversight & Government Reform Subcommittee on Information Technology, addressing CMS’s comprehensive plan for the removal of Social Security numbers and transition to MBIs.   Work on this important initiative began many years ago, and was accelerated following passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS will assign all Medicare beneficiaries a new, unique MBI number which will contain a combination of numbers and uppercase letters. Beneficiaries will be instructed to safely and securely destroy their current Medicare cards and keep the new MBI confidential. Issuance of the new MBI will not change the benefits a Medicare beneficiary receives.   CMS has a website dedicated to the Social Security Removal Initiative (SSNRI) where providers can find the latest information and sign-up for newsletters. CMS is also planning regular calls as a way to share updates and answer provider questions before and after new cards are mailed beginning in April 2018.   For more information, please visit: https://www.cms.gov/medicare/ssnri/index.html    Administration Releases Budget for FY 2018 The budget proposal includes $1.5 trillion in nondefense discretionary spending cuts, and would balance the budget within a decade. While the White House budget would drastically reshape federal spending on anti-poverty and safety net programs, it leaves the Medicare program untouched. The budget assumes that repeal and replacement of the Affordable Care Act (ACA) will be accomplished, resulting in estimated savings of $250 billion over the next ten years.   The budget features deep cuts to the U.S. Department of Health and Human Service (HHS) – totaling a reduction of $12.4 billion in discretionary funding.

  • Funding for the National Institutes of Health (NIH) would be reduced by nearly 20 percent, or $6 billion.
  • The budget proposes to decrease spending at the Centers for Disease Control and Prevention (CDC) by $1.3 billion, or 17 percent.
  • The budget proposal would consolidate the Agency for Healthcare Research and Quality (AHRQ) into the NIH, but maintain the Agency’s $272 million in discretionary funding. Additionally, the method by which AHRQ processes grants would be restructured in order to lower operating costs.
  • The President’s budget would increase industry user fees at the Food and Drug Administration (FDA) by almost 70 percent while reducing taxpayer funding for the agency by 30 percent. Congressional leadership has already said this proposal is definitely unfeasible given the current status of user fee negotiations.
  • The budget includes medical liability reforms as one of its major savings components. Proposals such as capping noneconomic damages, enactment of a statute of limitations, and creation of a safe harbor for clinicians are estimated to produce $55.8 billion in savings.
  • On the issue of drug pricing, the President’s budget expresses support for updating value-based purchasing arrangements, and for encouraging manufacturers to communicate with payers ahead of FDA approval. The White House budget proposal would also overhaul the Medicaid program in order to rein in entitlement spending. Medicaid’s federal funding would be capped, which would result in $610 billion in savings over the next decade.

Medicaid would be transitioned to either a block grant program or a per-capita limit. While states would receive a fixed amount of funding for Medicaid, they would be provided additional flexibility in the administration of the program. The budget proposal’s handling of Medicaid mirrors the policies contained in the House-passed American Health Care Act (AHCA), to repeal and replace Obamacare. The combined proposals would slash a total of $1.4 trillion from the Medicaid program. The budget proposal indicates the President’s interest in reforming the program regardless of whether AHCA becomes law. The President’s budget also includes a $5.8 billion cut to the Children’s Health Insurance Program (CHIP), along with a two-year extension of CHIP. While Republicans praised the President for his commitment to balancing the budget, most have distanced themselves from the budget proposal nonetheless.   Congressional Telehealth Caucus Launched Members of the House of Representatives have launched a coalition to bring awareness to the issue of technology use in the delivery of health care. The Congressional Telehealth Caucus will welcome input from stakeholders to educate lawmakers, particularly those outside of committees with Medicare jurisdiction, about the importance of telehealth.   The four founding members of the caucus are Reps. Mike Thompson (D-Calif.), Gregg Harper (R-Mass.), Diane Black (R-Tenn.), and Peter Welch (D-Vt.). The Medicare Telehealth Parity Act (H.R. 2550) and the CONNECT for Health Act (S. 1016) were also introduced last week. Both bills would improve reimbursement for and expand the use of telehealth services. Components of the CONNECT for Health Act were included as part of the CHRONIC Care Act (S.870), which was advanced by the Senate Finance Committee earlier this month.   CBO Scores the American Health Care Act The Congressional Budget Office (CBO) has released its score of the American Health Care Act (AHCA), which would repeal and replace Obamacare. Per the non-partisan budget agency, AHCA would lead to 23 million more uninsured over the next decade. This estimate is in keeping with previous versions of the bill. The House-passed legislation, however, would produce fewer savings than previous versions of the bill. CBO estimates that the AHCA would reduce the deficit by $119 billion over the next ten years, down from earlier projections of $151 billion and $337 billion. Premiums would increase for two years before decreasing by 20 percent in 2018 and five percent in 2019. CBO predicts that the changes to the Medicaid program would reduce coverage by 10 million people and cut program funding by $834 billion over the next decade. The agency also warns that the bill could undermine the stability of insurance markets in one-sixth of the country – those states which choose to waive ACA insurance regulations. As a result, older and sicker Americans would see a drastic increase in the cost of their insurance coverage. While the score was well-received by Speaker of the House Paul Ryan (R-Wis.) for confirming that the bill would lower the deficit, Secretary of the U.S. Department of Health and Human Services (HHS) Tom Price questioned the score’s accuracy. In the Senate, some Republican members warned that the CBO’s analysis underscored the need for the upper chamber to pass legislation that does more to protect those with pre-existing conditions. Majority Leader Mitch McConnell (R-Ky.), however, reiterated that the ACA status quo was unacceptable and unsustainable, regardless of the CBO report.   Senate Repeal Legislation Drafting Senate staff spent the week of Memorial Day recess drafting a health care bill and building consensus around a plan to repeal and replace the Affordable Care Act (ACA). Staff conferred with the Senate parliamentarian to discuss which aspects of Obamacare repeal and replacement can be accomplished through reconciliation. Majority Leader Mitch McConnell (R-Ky.) confirmed that he does not yet have the votes to bring repeal legislation to the Senate floor.   The biggest sticking point appears to be Medicaid – lawmakers in the Senate cannot seem to agree on how much to scale back Obamacare’s expansion, or how to rein in program spending. Additionally, there is still disagreement about whether to allow states to waive the health care law’s insurance regulations, which require coverage of essential health benefits and community rating. The Senate GOP is currently in the early stages of weighing a proposal to stabilize the insurance market in 2018 and 2019, while postponing ACA repeal until 2020. Lawmakers are also considering the idea of reinsurance as an alternative to the use of high-risk pools to provide coverage to high cost patients.   Lawmakers Request Clarification on HHS Whistleblower Memo Senate Judiciary Committee Chairman Chuck Grassley (R-Iowa) and House Oversight Committee Chairman Jason Chaffetz (R-Utah) have written to U.S. Department of Health and Human Services (HHS) Secretary Tom Price regarding HHS staff’s ability to speak to lawmakers. Agency employees received a memo telling them to contact the Office of the Assistant Secretary for Legislation prior to speaking with members of Congress. “Protecting whistleblowers who courageously speak out is not a partisan issue — it is critical to the functioning of our government,” the letter states. The lawmakers request that Secretary Price issue a clarification telling federal workers that they have a right to contact members of Congress.   Trump Seeks Further Delay in Health Care Subsidy Lawsuit The Trump administration again delayed a decision in a major case that could upend the health insurance markets created by the 2010 health care law, in a motion filed in federal court Monday. Justice Department lawyers asked in the motion for another 90-day delay in a case that centers on about $7 billion of annual subsidies that are aimed at making health care services more affordable for low-income people who gained coverage under the 2010 law.   The payments are “critical” to the success of the health marketplaces established by that law, insurance companies have testified to Congress. Without them, many insurers have warned they will stop selling plans in 2018.   Though the delay may be welcome politically, insurers were quick to decry the delay as bad policy. It leaves them facing uncertainty about a major aspect of the 2010 health care law’s funding, just as they must file their proposed 2018 health insurance premiums with state and federal policymakers. Some state deadlines for those proposals have already passed. The federal deadline is June 21.   The 90-day delay will force the companies to guess about the premiums they need to charge to cover the costs of insuring the individual market population. Regulators reviewing those rates will also have to speculate about whether the subsidies will remain in place. Some companies have suggested the uncertainty could force them to increase premiums by as much as 20 percent. Rates for the 2018 plan year are finalized throughout the fall according to various state and federal deadlines.  

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, HealthCare.gov.
    • 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 www.ProtectMyDoctorAndMe.com. 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: www.protectmydoctorandme.com. Also follow the discussion on Twitter at @MyDrAndMe