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Part D proposal includes prior authorization, step therapy
Rules governing the six protected medication classes covered by Medicare Part D could change under a proposal that would allow for utilization management or potential formulary exclusion of a drug for price increases.
Currently, Medicare Part D prescription drug benefit plans must cover “all or substantially all” approved drugs in six classes (antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics). The proposed rule would allow three exceptions aimed at giving plans more negotiating leverage to help lower prices.
Plans would be allowed to implement prior authorization and step therapy for protected-class drugs, “including to determine use for a protected class indication,” according to a fact sheet. They also could exclude a protected-class drug from their formulary “if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market.”
This does not change requirements that at least two drugs per class be covered, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said at a Nov. 26 briefing. “In some classes, there are lots of competitors. For example, for antidepressants, there are lots of new generics available, so we see plans being in a very strengthened negotiating position. But in other classes, where there may not be as many drugs that are available, you might not see the same type of step therapy and prior authorization because there are just not that many options. It is really going to depend on the class of drugs and what’s available and the plans’ ability to negotiate discounts with manufacturers.”
Plans could exclude a protected-class drug if its price had increased greater than inflation, Ms. Verma said, but they could not use this to not cover any drugs in a class if available options are limited to one or two drugs.
“Foremost in our minds was the impact on patients and ensuring affordability and access to prescription drugs,” Ms. Verma said.
Oncologists don’t seem to agree.
“For the first time ever, Medicare patients with cancer and other serious diseases [who] rely on drugs in these protected therapeutic categories, will no longer have guaranteed access to potentially life-saving drugs. Instead, they will be subjected to ‘fail first’ step therapy and formulary restrictions that potentially restrict them from receiving the evidence-based therapies that their trained physicians prescribe as first-line cancer treatment,” Jeff Vacirca, MD, president of the Community Oncology Alliance, said in a statement. “Step therapy requirements are driven by financial interests to save money and not by what is in the best medical interest of patients. Treatment decisions are made by nameless and faceless corporate bureaucrats who are often not board certified in the diseases they are making coverage decisions over.”
The proposal also would codify a policy implemented for 2019 that allows Medicare Advantage to implement step therapy tools for Part B drugs. And like the 2019 policy, the proposal would apply to new medication starts only, must be reviewed by a plan’s pharmacy and therapeutics committee, and must have an expedited exceptions process.
The proposal also specifically allows pharmacists to advise Part D beneficiaries on lower-cost options – something current regulations prohibit – and would require Part D explanation of benefits forms to include drug pricing information and lower-cost therapeutic alternatives.
The proposal is part of a broader update for Medicare Parts C and D in 2020 issued by CMS. It was published online Nov. 26 and is scheduled for publication in the Federal Register on Nov. 30. Comments can be made at www.regulations.gov through Jan. 25, 2019.
Rules governing the six protected medication classes covered by Medicare Part D could change under a proposal that would allow for utilization management or potential formulary exclusion of a drug for price increases.
Currently, Medicare Part D prescription drug benefit plans must cover “all or substantially all” approved drugs in six classes (antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics). The proposed rule would allow three exceptions aimed at giving plans more negotiating leverage to help lower prices.
Plans would be allowed to implement prior authorization and step therapy for protected-class drugs, “including to determine use for a protected class indication,” according to a fact sheet. They also could exclude a protected-class drug from their formulary “if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market.”
This does not change requirements that at least two drugs per class be covered, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said at a Nov. 26 briefing. “In some classes, there are lots of competitors. For example, for antidepressants, there are lots of new generics available, so we see plans being in a very strengthened negotiating position. But in other classes, where there may not be as many drugs that are available, you might not see the same type of step therapy and prior authorization because there are just not that many options. It is really going to depend on the class of drugs and what’s available and the plans’ ability to negotiate discounts with manufacturers.”
Plans could exclude a protected-class drug if its price had increased greater than inflation, Ms. Verma said, but they could not use this to not cover any drugs in a class if available options are limited to one or two drugs.
“Foremost in our minds was the impact on patients and ensuring affordability and access to prescription drugs,” Ms. Verma said.
Oncologists don’t seem to agree.
“For the first time ever, Medicare patients with cancer and other serious diseases [who] rely on drugs in these protected therapeutic categories, will no longer have guaranteed access to potentially life-saving drugs. Instead, they will be subjected to ‘fail first’ step therapy and formulary restrictions that potentially restrict them from receiving the evidence-based therapies that their trained physicians prescribe as first-line cancer treatment,” Jeff Vacirca, MD, president of the Community Oncology Alliance, said in a statement. “Step therapy requirements are driven by financial interests to save money and not by what is in the best medical interest of patients. Treatment decisions are made by nameless and faceless corporate bureaucrats who are often not board certified in the diseases they are making coverage decisions over.”
The proposal also would codify a policy implemented for 2019 that allows Medicare Advantage to implement step therapy tools for Part B drugs. And like the 2019 policy, the proposal would apply to new medication starts only, must be reviewed by a plan’s pharmacy and therapeutics committee, and must have an expedited exceptions process.
The proposal also specifically allows pharmacists to advise Part D beneficiaries on lower-cost options – something current regulations prohibit – and would require Part D explanation of benefits forms to include drug pricing information and lower-cost therapeutic alternatives.
The proposal is part of a broader update for Medicare Parts C and D in 2020 issued by CMS. It was published online Nov. 26 and is scheduled for publication in the Federal Register on Nov. 30. Comments can be made at www.regulations.gov through Jan. 25, 2019.
Rules governing the six protected medication classes covered by Medicare Part D could change under a proposal that would allow for utilization management or potential formulary exclusion of a drug for price increases.
Currently, Medicare Part D prescription drug benefit plans must cover “all or substantially all” approved drugs in six classes (antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics). The proposed rule would allow three exceptions aimed at giving plans more negotiating leverage to help lower prices.
Plans would be allowed to implement prior authorization and step therapy for protected-class drugs, “including to determine use for a protected class indication,” according to a fact sheet. They also could exclude a protected-class drug from their formulary “if the drug represents only a new formulation of an existing single-source drug or biological product, regardless of whether the older formulation remains on the market.”
This does not change requirements that at least two drugs per class be covered, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said at a Nov. 26 briefing. “In some classes, there are lots of competitors. For example, for antidepressants, there are lots of new generics available, so we see plans being in a very strengthened negotiating position. But in other classes, where there may not be as many drugs that are available, you might not see the same type of step therapy and prior authorization because there are just not that many options. It is really going to depend on the class of drugs and what’s available and the plans’ ability to negotiate discounts with manufacturers.”
Plans could exclude a protected-class drug if its price had increased greater than inflation, Ms. Verma said, but they could not use this to not cover any drugs in a class if available options are limited to one or two drugs.
“Foremost in our minds was the impact on patients and ensuring affordability and access to prescription drugs,” Ms. Verma said.
Oncologists don’t seem to agree.
“For the first time ever, Medicare patients with cancer and other serious diseases [who] rely on drugs in these protected therapeutic categories, will no longer have guaranteed access to potentially life-saving drugs. Instead, they will be subjected to ‘fail first’ step therapy and formulary restrictions that potentially restrict them from receiving the evidence-based therapies that their trained physicians prescribe as first-line cancer treatment,” Jeff Vacirca, MD, president of the Community Oncology Alliance, said in a statement. “Step therapy requirements are driven by financial interests to save money and not by what is in the best medical interest of patients. Treatment decisions are made by nameless and faceless corporate bureaucrats who are often not board certified in the diseases they are making coverage decisions over.”
The proposal also would codify a policy implemented for 2019 that allows Medicare Advantage to implement step therapy tools for Part B drugs. And like the 2019 policy, the proposal would apply to new medication starts only, must be reviewed by a plan’s pharmacy and therapeutics committee, and must have an expedited exceptions process.
The proposal also specifically allows pharmacists to advise Part D beneficiaries on lower-cost options – something current regulations prohibit – and would require Part D explanation of benefits forms to include drug pricing information and lower-cost therapeutic alternatives.
The proposal is part of a broader update for Medicare Parts C and D in 2020 issued by CMS. It was published online Nov. 26 and is scheduled for publication in the Federal Register on Nov. 30. Comments can be made at www.regulations.gov through Jan. 25, 2019.
FDA aims to squash youth vaping, smoking
The Food and Drug Administration once again has upped the ante in its war on youth smoking and vaping.
“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids,” FDA Commissioner Scott Gottlieb, MD, said in a statement.
First and foremost, the FDA wants to reduce the lure of e-cigarettes by limiting the variety of flavored products for sale in retail outlets. Under the proposal unveiled Nov. 15, only electronic nicotine delivery systems (ENDS) that are unflavored or have tobacco, mint, or menthol flavors would be widely available. Flavored products – think cherry, cotton candy, and mango – would be sold in age-restricted environments, such as stand-alone tobacco retailers like vape shops. The FDA also seeks more stringent enforcement of age verification on ENDS products sold online.
The proposal also would reexamine regulations governing flavored cigars, with the possible aim of banning them.
“These efforts to address flavors and protect youth would dramatically impact the ability of American kids to access tobacco products that we know are both appealing and addicting,” Dr. Gottlieb said in a statement. “This policy framework reflects a redoubling of the FDA’s efforts to protect kids from all nicotine-containing products.”
In a move that seems to be aimed at youth-oriented products like Juul, the FDA will be seeking to remove from the market any ENDS product that is marketed specifically to young people.
Finally, the FDA intends to pursue regulation that would ban menthol from combustible tobacco products.
“I believe these menthol-flavored products represent one of the most common and pernicious routes by which kids initiate on combustible cigarettes,” Dr. Gottlieb said. “The menthol serves to mask some of the unattractive features of smoking that might otherwise discourage a child from smoking. Moreover, I believe that menthol products disproportionately and adversely affect underserved communities. And as a matter of public health, they exacerbate troubling disparities in health related to race and socioeconomic status.”
The policy shift comes as the Centers for Disease Control and Prevention released data from the 2018 National Youth Tobacco Survey showing that use of e-cigarettes among high schoolers is on the rise, growing from 1.5% in 2011 to 20.8% in 2018. Middle schoolers saw use over the same time period increase from 0.6% to 4.9%.
The rise of current use of e-cigarettes was enough to reverse a declining trend in overall tobacco use in recent years between 2015 and 2017.
“FDA’s enforcement efforts and policy framework would restrict access to most flavored e-cigarettes and limit the chances of youth beginning to use these products, while ensuring the products are available to adult smokers as an alternative to combustible cigarettes,” Alex M. Azar II, secretary of the Department of Health & Human Services, said in a statement supporting the FDA’s efforts. “Our obligation at HHS is always to the public health, and we believe FDA’s goals strike the right public health balance in addressing the multifaceted challenge we have before us today.”
Under Dr. Gottlieb, the FDA has been aggressively pursuing ways to reduce tobacco consumption, targeting both ENDS and combustible tobacco regulations in an effort to limit nicotine exposure and reduce the number of people addicted to nicotine and the health issues that come with it.
The American College of Cardiology voiced its support of the FDA’s actions.
“The FDA’s announcement restricting the sale of flavored e-cigarettes and other tobacco products shows they are ready to do their part in making tobacco products less available to our children,” ACC President C. Michael Valentine, MD, said in a statement, adding that the medical community needs to continue to do its part to make sure tobacco use continues to decline, especially in the nonadult population.
The FDA proposals were published as part of an advance notice of proposed rulemaking in the Federal Register. Comments can be made at www.regulations.gov through June 19.
The Food and Drug Administration once again has upped the ante in its war on youth smoking and vaping.
“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids,” FDA Commissioner Scott Gottlieb, MD, said in a statement.
First and foremost, the FDA wants to reduce the lure of e-cigarettes by limiting the variety of flavored products for sale in retail outlets. Under the proposal unveiled Nov. 15, only electronic nicotine delivery systems (ENDS) that are unflavored or have tobacco, mint, or menthol flavors would be widely available. Flavored products – think cherry, cotton candy, and mango – would be sold in age-restricted environments, such as stand-alone tobacco retailers like vape shops. The FDA also seeks more stringent enforcement of age verification on ENDS products sold online.
The proposal also would reexamine regulations governing flavored cigars, with the possible aim of banning them.
“These efforts to address flavors and protect youth would dramatically impact the ability of American kids to access tobacco products that we know are both appealing and addicting,” Dr. Gottlieb said in a statement. “This policy framework reflects a redoubling of the FDA’s efforts to protect kids from all nicotine-containing products.”
In a move that seems to be aimed at youth-oriented products like Juul, the FDA will be seeking to remove from the market any ENDS product that is marketed specifically to young people.
Finally, the FDA intends to pursue regulation that would ban menthol from combustible tobacco products.
“I believe these menthol-flavored products represent one of the most common and pernicious routes by which kids initiate on combustible cigarettes,” Dr. Gottlieb said. “The menthol serves to mask some of the unattractive features of smoking that might otherwise discourage a child from smoking. Moreover, I believe that menthol products disproportionately and adversely affect underserved communities. And as a matter of public health, they exacerbate troubling disparities in health related to race and socioeconomic status.”
The policy shift comes as the Centers for Disease Control and Prevention released data from the 2018 National Youth Tobacco Survey showing that use of e-cigarettes among high schoolers is on the rise, growing from 1.5% in 2011 to 20.8% in 2018. Middle schoolers saw use over the same time period increase from 0.6% to 4.9%.
The rise of current use of e-cigarettes was enough to reverse a declining trend in overall tobacco use in recent years between 2015 and 2017.
“FDA’s enforcement efforts and policy framework would restrict access to most flavored e-cigarettes and limit the chances of youth beginning to use these products, while ensuring the products are available to adult smokers as an alternative to combustible cigarettes,” Alex M. Azar II, secretary of the Department of Health & Human Services, said in a statement supporting the FDA’s efforts. “Our obligation at HHS is always to the public health, and we believe FDA’s goals strike the right public health balance in addressing the multifaceted challenge we have before us today.”
Under Dr. Gottlieb, the FDA has been aggressively pursuing ways to reduce tobacco consumption, targeting both ENDS and combustible tobacco regulations in an effort to limit nicotine exposure and reduce the number of people addicted to nicotine and the health issues that come with it.
The American College of Cardiology voiced its support of the FDA’s actions.
“The FDA’s announcement restricting the sale of flavored e-cigarettes and other tobacco products shows they are ready to do their part in making tobacco products less available to our children,” ACC President C. Michael Valentine, MD, said in a statement, adding that the medical community needs to continue to do its part to make sure tobacco use continues to decline, especially in the nonadult population.
The FDA proposals were published as part of an advance notice of proposed rulemaking in the Federal Register. Comments can be made at www.regulations.gov through June 19.
The Food and Drug Administration once again has upped the ante in its war on youth smoking and vaping.
“Today, I’m pursuing actions aimed at addressing the disturbing trend of youth nicotine use and continuing to advance the historic declines we’ve achieved in recent years in the rates of combustible cigarette use among kids,” FDA Commissioner Scott Gottlieb, MD, said in a statement.
First and foremost, the FDA wants to reduce the lure of e-cigarettes by limiting the variety of flavored products for sale in retail outlets. Under the proposal unveiled Nov. 15, only electronic nicotine delivery systems (ENDS) that are unflavored or have tobacco, mint, or menthol flavors would be widely available. Flavored products – think cherry, cotton candy, and mango – would be sold in age-restricted environments, such as stand-alone tobacco retailers like vape shops. The FDA also seeks more stringent enforcement of age verification on ENDS products sold online.
The proposal also would reexamine regulations governing flavored cigars, with the possible aim of banning them.
“These efforts to address flavors and protect youth would dramatically impact the ability of American kids to access tobacco products that we know are both appealing and addicting,” Dr. Gottlieb said in a statement. “This policy framework reflects a redoubling of the FDA’s efforts to protect kids from all nicotine-containing products.”
In a move that seems to be aimed at youth-oriented products like Juul, the FDA will be seeking to remove from the market any ENDS product that is marketed specifically to young people.
Finally, the FDA intends to pursue regulation that would ban menthol from combustible tobacco products.
“I believe these menthol-flavored products represent one of the most common and pernicious routes by which kids initiate on combustible cigarettes,” Dr. Gottlieb said. “The menthol serves to mask some of the unattractive features of smoking that might otherwise discourage a child from smoking. Moreover, I believe that menthol products disproportionately and adversely affect underserved communities. And as a matter of public health, they exacerbate troubling disparities in health related to race and socioeconomic status.”
The policy shift comes as the Centers for Disease Control and Prevention released data from the 2018 National Youth Tobacco Survey showing that use of e-cigarettes among high schoolers is on the rise, growing from 1.5% in 2011 to 20.8% in 2018. Middle schoolers saw use over the same time period increase from 0.6% to 4.9%.
The rise of current use of e-cigarettes was enough to reverse a declining trend in overall tobacco use in recent years between 2015 and 2017.
“FDA’s enforcement efforts and policy framework would restrict access to most flavored e-cigarettes and limit the chances of youth beginning to use these products, while ensuring the products are available to adult smokers as an alternative to combustible cigarettes,” Alex M. Azar II, secretary of the Department of Health & Human Services, said in a statement supporting the FDA’s efforts. “Our obligation at HHS is always to the public health, and we believe FDA’s goals strike the right public health balance in addressing the multifaceted challenge we have before us today.”
Under Dr. Gottlieb, the FDA has been aggressively pursuing ways to reduce tobacco consumption, targeting both ENDS and combustible tobacco regulations in an effort to limit nicotine exposure and reduce the number of people addicted to nicotine and the health issues that come with it.
The American College of Cardiology voiced its support of the FDA’s actions.
“The FDA’s announcement restricting the sale of flavored e-cigarettes and other tobacco products shows they are ready to do their part in making tobacco products less available to our children,” ACC President C. Michael Valentine, MD, said in a statement, adding that the medical community needs to continue to do its part to make sure tobacco use continues to decline, especially in the nonadult population.
The FDA proposals were published as part of an advance notice of proposed rulemaking in the Federal Register. Comments can be made at www.regulations.gov through June 19.
ACP beefs up firearms policy
The American College of Physicians supports appropriate regulations surrounding the purchase of firearms; best practices ownership, storage, and safe use to minimize the risk of accidental or intentional death or injury; and a ban on civilian use of semiautomatic weapons and large capacity magazines, according to an expanded and updated policy statement issued Oct. 29.
The updated policy statement was issued at the end of a week that saw a mass shooting at a Pittsburgh synagogue where 11 people were killed as well as an incident in which two others were shot to death in a Kentucky grocery store.
“Physicians regularly come face to face with the tragedy that gun violence brings, whether maliciously or unintentionally,” ACP President Ana María López, MD, said in a statement after the synagogue shooting. “The rate of injuries and deaths related to firearms and the growing incidence of mass shootings brings to light, once again, the glaring lack of firearm policy in the United States – a country with one of the highest rates of gun violence in the world. This most recent event makes it more important than ever that Congress and states implement common-sense policies that could prevent injuries and deaths from firearms.”
The policy statement reaffirms all policies included in the college’s 2014 policy.
New to the ACP policy is the college’s support for “appropriate regulation of the purchase of legal firearms to reduce firearms-related injuries and deaths.” ACP specifies that any policy “must be consistent with the Supreme Court ruling establishing that individual ownership of firearms is a constitutional right under the Second Amendment of the Bill of Rights.”
The expanded policy calls for universal criminal background checks for firearms purchase and completion of an educational program on firearm safety; strengthening and enforcing laws on prohibiting convicted domestic violence offenders from purchasing firearms; banning firearms that cannot be detected by metal detectors and standard security screening devices; and a reexamining of concealed carry laws. ACP also favors strong penalties and criminal prosecution for those who sell firearms illegally and for those who legally purchase firearms for the sole purpose of acting as the purchaser for someone who is not legally able to possess the firearm.
The policy also “favors enactment of legislation to ban the manufacture, sale, transfer, and subsequent ownership for civilian use of semiautomatic firearms that are designed to increase their rapid killing capacity (often called ‘assault weapons’) and large-capacity magazines, and retaining the current ban on automatic weapons for civilian use.”
As part of this, ACP is calling for a comprehensive definition of semiautomatic firearms that would be subject to the ban as well as a definition of sporting and hunting purposes that should be narrowly defined.
The policy also calls for raising of the minimum age to purchase a semiautomatic weapon to 21 years, prior to the full ban being put in place.
Finally, ACP is calling on firearm owners to “adhere to best practices to reduce the risk of accidental or intentional injuries or deaths from firearms,” including ensuring that firearms “cannot be accessed by children, adolescents, people with dementia, people with substance use disorder, and the subset of people with serious mental illness that are associated with greater risk of harming themselves and others.”
Finally, the expanded policy calls for enactment of extreme risk protection order laws, under which a family member or law enforcement officer can seek a court order to temporarily remove firearms from an individual who is at imminent risk of self-harm or to others, while preserving the individual’s due process protections.
[email protected]
SOURCE: Butkus R et al. Ann Intern Med. 2018 Oct 29. doi: 10.7326/M18-1530.
“Do you have guns in the home?”
This simple question should be asked as if it were any other question about health status and potentially unsafe behavior that doctors routinely ask.
It opens the door to further discuss firearms-related issues, especially if there is a concern regarding the patient’s mental state that could impact the health and safety of the patient or others around the individual.
James Kahn, MD, of Stanford (Calif.) University, makes this suggestion in an editorial accompanying the ACP policy statement (Ann Intern Med. 2018 Oct 29. doi: 10.7326/M18-2756).
“Do you have guns in the home?”
This simple question should be asked as if it were any other question about health status and potentially unsafe behavior that doctors routinely ask.
It opens the door to further discuss firearms-related issues, especially if there is a concern regarding the patient’s mental state that could impact the health and safety of the patient or others around the individual.
James Kahn, MD, of Stanford (Calif.) University, makes this suggestion in an editorial accompanying the ACP policy statement (Ann Intern Med. 2018 Oct 29. doi: 10.7326/M18-2756).
“Do you have guns in the home?”
This simple question should be asked as if it were any other question about health status and potentially unsafe behavior that doctors routinely ask.
It opens the door to further discuss firearms-related issues, especially if there is a concern regarding the patient’s mental state that could impact the health and safety of the patient or others around the individual.
James Kahn, MD, of Stanford (Calif.) University, makes this suggestion in an editorial accompanying the ACP policy statement (Ann Intern Med. 2018 Oct 29. doi: 10.7326/M18-2756).
The American College of Physicians supports appropriate regulations surrounding the purchase of firearms; best practices ownership, storage, and safe use to minimize the risk of accidental or intentional death or injury; and a ban on civilian use of semiautomatic weapons and large capacity magazines, according to an expanded and updated policy statement issued Oct. 29.
The updated policy statement was issued at the end of a week that saw a mass shooting at a Pittsburgh synagogue where 11 people were killed as well as an incident in which two others were shot to death in a Kentucky grocery store.
“Physicians regularly come face to face with the tragedy that gun violence brings, whether maliciously or unintentionally,” ACP President Ana María López, MD, said in a statement after the synagogue shooting. “The rate of injuries and deaths related to firearms and the growing incidence of mass shootings brings to light, once again, the glaring lack of firearm policy in the United States – a country with one of the highest rates of gun violence in the world. This most recent event makes it more important than ever that Congress and states implement common-sense policies that could prevent injuries and deaths from firearms.”
The policy statement reaffirms all policies included in the college’s 2014 policy.
New to the ACP policy is the college’s support for “appropriate regulation of the purchase of legal firearms to reduce firearms-related injuries and deaths.” ACP specifies that any policy “must be consistent with the Supreme Court ruling establishing that individual ownership of firearms is a constitutional right under the Second Amendment of the Bill of Rights.”
The expanded policy calls for universal criminal background checks for firearms purchase and completion of an educational program on firearm safety; strengthening and enforcing laws on prohibiting convicted domestic violence offenders from purchasing firearms; banning firearms that cannot be detected by metal detectors and standard security screening devices; and a reexamining of concealed carry laws. ACP also favors strong penalties and criminal prosecution for those who sell firearms illegally and for those who legally purchase firearms for the sole purpose of acting as the purchaser for someone who is not legally able to possess the firearm.
The policy also “favors enactment of legislation to ban the manufacture, sale, transfer, and subsequent ownership for civilian use of semiautomatic firearms that are designed to increase their rapid killing capacity (often called ‘assault weapons’) and large-capacity magazines, and retaining the current ban on automatic weapons for civilian use.”
As part of this, ACP is calling for a comprehensive definition of semiautomatic firearms that would be subject to the ban as well as a definition of sporting and hunting purposes that should be narrowly defined.
The policy also calls for raising of the minimum age to purchase a semiautomatic weapon to 21 years, prior to the full ban being put in place.
Finally, ACP is calling on firearm owners to “adhere to best practices to reduce the risk of accidental or intentional injuries or deaths from firearms,” including ensuring that firearms “cannot be accessed by children, adolescents, people with dementia, people with substance use disorder, and the subset of people with serious mental illness that are associated with greater risk of harming themselves and others.”
Finally, the expanded policy calls for enactment of extreme risk protection order laws, under which a family member or law enforcement officer can seek a court order to temporarily remove firearms from an individual who is at imminent risk of self-harm or to others, while preserving the individual’s due process protections.
[email protected]
SOURCE: Butkus R et al. Ann Intern Med. 2018 Oct 29. doi: 10.7326/M18-1530.
The American College of Physicians supports appropriate regulations surrounding the purchase of firearms; best practices ownership, storage, and safe use to minimize the risk of accidental or intentional death or injury; and a ban on civilian use of semiautomatic weapons and large capacity magazines, according to an expanded and updated policy statement issued Oct. 29.
The updated policy statement was issued at the end of a week that saw a mass shooting at a Pittsburgh synagogue where 11 people were killed as well as an incident in which two others were shot to death in a Kentucky grocery store.
“Physicians regularly come face to face with the tragedy that gun violence brings, whether maliciously or unintentionally,” ACP President Ana María López, MD, said in a statement after the synagogue shooting. “The rate of injuries and deaths related to firearms and the growing incidence of mass shootings brings to light, once again, the glaring lack of firearm policy in the United States – a country with one of the highest rates of gun violence in the world. This most recent event makes it more important than ever that Congress and states implement common-sense policies that could prevent injuries and deaths from firearms.”
The policy statement reaffirms all policies included in the college’s 2014 policy.
New to the ACP policy is the college’s support for “appropriate regulation of the purchase of legal firearms to reduce firearms-related injuries and deaths.” ACP specifies that any policy “must be consistent with the Supreme Court ruling establishing that individual ownership of firearms is a constitutional right under the Second Amendment of the Bill of Rights.”
The expanded policy calls for universal criminal background checks for firearms purchase and completion of an educational program on firearm safety; strengthening and enforcing laws on prohibiting convicted domestic violence offenders from purchasing firearms; banning firearms that cannot be detected by metal detectors and standard security screening devices; and a reexamining of concealed carry laws. ACP also favors strong penalties and criminal prosecution for those who sell firearms illegally and for those who legally purchase firearms for the sole purpose of acting as the purchaser for someone who is not legally able to possess the firearm.
The policy also “favors enactment of legislation to ban the manufacture, sale, transfer, and subsequent ownership for civilian use of semiautomatic firearms that are designed to increase their rapid killing capacity (often called ‘assault weapons’) and large-capacity magazines, and retaining the current ban on automatic weapons for civilian use.”
As part of this, ACP is calling for a comprehensive definition of semiautomatic firearms that would be subject to the ban as well as a definition of sporting and hunting purposes that should be narrowly defined.
The policy also calls for raising of the minimum age to purchase a semiautomatic weapon to 21 years, prior to the full ban being put in place.
Finally, ACP is calling on firearm owners to “adhere to best practices to reduce the risk of accidental or intentional injuries or deaths from firearms,” including ensuring that firearms “cannot be accessed by children, adolescents, people with dementia, people with substance use disorder, and the subset of people with serious mental illness that are associated with greater risk of harming themselves and others.”
Finally, the expanded policy calls for enactment of extreme risk protection order laws, under which a family member or law enforcement officer can seek a court order to temporarily remove firearms from an individual who is at imminent risk of self-harm or to others, while preserving the individual’s due process protections.
[email protected]
SOURCE: Butkus R et al. Ann Intern Med. 2018 Oct 29. doi: 10.7326/M18-1530.
FROM ANNALS OF INTERNAL MEDICINE
Trump scheme for Part B drugs raises red flags
A proposed Trump administration plan for paying for drugs under Medicare Part B has raised red flags for doctors.
The Centers for Medicare & Medicaid Services announced Oct. 25 that it will test paying for Part B drugs by more closely aligning those payments with international rates.
The so-called International Price Index (IPI) model “would test whether increasing competition for private-sector vendors to negotiate drug prices, and aligning Medicare payments for drugs with prices that are paid in foreign countries, improves beneficiary access and quality of care while reducing expenditures,” according to a government fact sheet.
Under the test, private vendors would “procure drugs, distribute them to physicians and hospitals, and take on the responsibility of billing Medicare. Vendors would aggregate purchasing, seek volume-based discounts, and compete for providers’ business, thereby creating competition where none exists today.”
Health care professionals and hospitals in certain geographic areas would receive their Part B drugs under this program, while the rest of the country would continue under the current buy-and-bill system. Eventually, over the 5-year phase-in period, half of the geographic regions would fall under this IPI model.
CMS officials note that the IPI model “would maintain beneficiaries’ choice of provider and treatments and would have meaningful beneficiary protections such as enhanced monitoring and Medicare Beneficiary Ombudsman supports.”
Initially, only single-source drugs and biologics with available international pricing data would be provided under the IPI model, which could be expanded over time to include drugs available via multiple sources.
Currently, Medicare typically pays average sales price (ASP) plus a 6% add-on for drugs under Part B. Under IPI, if the international price is determined to be lower than the ASP, the CMS would reimburse based on a target price derived from an international price index, with the hope that manufacturers would match the international price. The target price would be phased in over a 5-year period.
The plan also calls for an add-on price similar to the current buy-and-bill system; however, the CMS aims to bring the add-on back to 6% rather than the actual 4.3% under the budget sequestration.
Other add-ons are also under consideration, such as paying a fixed amount per encounter or per month as well as a unique payment based on drug class, physician specialty, or physician practice.
Early takes on the proposal were met with skepticism.
The Community Oncology Alliance (COA) said in a statement that it is “concerned that the IPI will either repeat past reform mistakes [such as the Competitive Acquisition Program] or introduce the same cancer treatment access challenges experienced by cancer patients today with pharmacy benefit managers and other middlemen under Medicare Part D.”
“What the administration is proposing is incredibly complex and extremely difficult to comprehend how it would be implemented in the real-world of medical practice,” said Ted Okon, executive director of the COA. “It is also disturbing that the administration is trying to end-run the Congress by forcing a mandatory CMS Innovation Center demonstration that will effectively change Medicare reimbursement, as the sequester cut to Part B drug reimbursement has already done.”
The American College of Rheumatology was more measured in its reaction, noting that any change in policy needs to be thoughtful in its process to ensure that patient care is not adversely affected.
“Efforts to address high costs can sometimes create significant access issues for patients while penalizing doctors for providing quality care,” ACR officials said in a statement. “These proposals include those restructuring reimbursement for Medicare Part B drugs through either flat fee payments or a competitive acquisition program, or allowing utilization management such as step therapy or ‘fail first’ protocols in the Medicare Part B program. It is imperative that policy makers stay focused on the players who control drug prices and not penalize Medicare patients who depend on timely access to needed therapies.”
The American Medical Association raised some concerns as well.
“The administration’s proposal for an International Pricing Index Model for Part B drugs raises a number of questions, and we need to have a greater understanding of the potential impact of the proposal on patients, physicians, and the health care system,” AMA President Barbara McAneny, MD, said in a statement. “We look forward to working constructively with the Administration as it seeks feedback.”
The advanced notice of proposed rulemaking was posted to the Federal Register website on Oct. 25 and is scheduled to be formally published in the publication on Oct. 30. Comments are due Dec. 24. The CMS plans to issue the proposed rule related to this model in the spring of 2019.
A proposed Trump administration plan for paying for drugs under Medicare Part B has raised red flags for doctors.
The Centers for Medicare & Medicaid Services announced Oct. 25 that it will test paying for Part B drugs by more closely aligning those payments with international rates.
The so-called International Price Index (IPI) model “would test whether increasing competition for private-sector vendors to negotiate drug prices, and aligning Medicare payments for drugs with prices that are paid in foreign countries, improves beneficiary access and quality of care while reducing expenditures,” according to a government fact sheet.
Under the test, private vendors would “procure drugs, distribute them to physicians and hospitals, and take on the responsibility of billing Medicare. Vendors would aggregate purchasing, seek volume-based discounts, and compete for providers’ business, thereby creating competition where none exists today.”
Health care professionals and hospitals in certain geographic areas would receive their Part B drugs under this program, while the rest of the country would continue under the current buy-and-bill system. Eventually, over the 5-year phase-in period, half of the geographic regions would fall under this IPI model.
CMS officials note that the IPI model “would maintain beneficiaries’ choice of provider and treatments and would have meaningful beneficiary protections such as enhanced monitoring and Medicare Beneficiary Ombudsman supports.”
Initially, only single-source drugs and biologics with available international pricing data would be provided under the IPI model, which could be expanded over time to include drugs available via multiple sources.
Currently, Medicare typically pays average sales price (ASP) plus a 6% add-on for drugs under Part B. Under IPI, if the international price is determined to be lower than the ASP, the CMS would reimburse based on a target price derived from an international price index, with the hope that manufacturers would match the international price. The target price would be phased in over a 5-year period.
The plan also calls for an add-on price similar to the current buy-and-bill system; however, the CMS aims to bring the add-on back to 6% rather than the actual 4.3% under the budget sequestration.
Other add-ons are also under consideration, such as paying a fixed amount per encounter or per month as well as a unique payment based on drug class, physician specialty, or physician practice.
Early takes on the proposal were met with skepticism.
The Community Oncology Alliance (COA) said in a statement that it is “concerned that the IPI will either repeat past reform mistakes [such as the Competitive Acquisition Program] or introduce the same cancer treatment access challenges experienced by cancer patients today with pharmacy benefit managers and other middlemen under Medicare Part D.”
“What the administration is proposing is incredibly complex and extremely difficult to comprehend how it would be implemented in the real-world of medical practice,” said Ted Okon, executive director of the COA. “It is also disturbing that the administration is trying to end-run the Congress by forcing a mandatory CMS Innovation Center demonstration that will effectively change Medicare reimbursement, as the sequester cut to Part B drug reimbursement has already done.”
The American College of Rheumatology was more measured in its reaction, noting that any change in policy needs to be thoughtful in its process to ensure that patient care is not adversely affected.
“Efforts to address high costs can sometimes create significant access issues for patients while penalizing doctors for providing quality care,” ACR officials said in a statement. “These proposals include those restructuring reimbursement for Medicare Part B drugs through either flat fee payments or a competitive acquisition program, or allowing utilization management such as step therapy or ‘fail first’ protocols in the Medicare Part B program. It is imperative that policy makers stay focused on the players who control drug prices and not penalize Medicare patients who depend on timely access to needed therapies.”
The American Medical Association raised some concerns as well.
“The administration’s proposal for an International Pricing Index Model for Part B drugs raises a number of questions, and we need to have a greater understanding of the potential impact of the proposal on patients, physicians, and the health care system,” AMA President Barbara McAneny, MD, said in a statement. “We look forward to working constructively with the Administration as it seeks feedback.”
The advanced notice of proposed rulemaking was posted to the Federal Register website on Oct. 25 and is scheduled to be formally published in the publication on Oct. 30. Comments are due Dec. 24. The CMS plans to issue the proposed rule related to this model in the spring of 2019.
A proposed Trump administration plan for paying for drugs under Medicare Part B has raised red flags for doctors.
The Centers for Medicare & Medicaid Services announced Oct. 25 that it will test paying for Part B drugs by more closely aligning those payments with international rates.
The so-called International Price Index (IPI) model “would test whether increasing competition for private-sector vendors to negotiate drug prices, and aligning Medicare payments for drugs with prices that are paid in foreign countries, improves beneficiary access and quality of care while reducing expenditures,” according to a government fact sheet.
Under the test, private vendors would “procure drugs, distribute them to physicians and hospitals, and take on the responsibility of billing Medicare. Vendors would aggregate purchasing, seek volume-based discounts, and compete for providers’ business, thereby creating competition where none exists today.”
Health care professionals and hospitals in certain geographic areas would receive their Part B drugs under this program, while the rest of the country would continue under the current buy-and-bill system. Eventually, over the 5-year phase-in period, half of the geographic regions would fall under this IPI model.
CMS officials note that the IPI model “would maintain beneficiaries’ choice of provider and treatments and would have meaningful beneficiary protections such as enhanced monitoring and Medicare Beneficiary Ombudsman supports.”
Initially, only single-source drugs and biologics with available international pricing data would be provided under the IPI model, which could be expanded over time to include drugs available via multiple sources.
Currently, Medicare typically pays average sales price (ASP) plus a 6% add-on for drugs under Part B. Under IPI, if the international price is determined to be lower than the ASP, the CMS would reimburse based on a target price derived from an international price index, with the hope that manufacturers would match the international price. The target price would be phased in over a 5-year period.
The plan also calls for an add-on price similar to the current buy-and-bill system; however, the CMS aims to bring the add-on back to 6% rather than the actual 4.3% under the budget sequestration.
Other add-ons are also under consideration, such as paying a fixed amount per encounter or per month as well as a unique payment based on drug class, physician specialty, or physician practice.
Early takes on the proposal were met with skepticism.
The Community Oncology Alliance (COA) said in a statement that it is “concerned that the IPI will either repeat past reform mistakes [such as the Competitive Acquisition Program] or introduce the same cancer treatment access challenges experienced by cancer patients today with pharmacy benefit managers and other middlemen under Medicare Part D.”
“What the administration is proposing is incredibly complex and extremely difficult to comprehend how it would be implemented in the real-world of medical practice,” said Ted Okon, executive director of the COA. “It is also disturbing that the administration is trying to end-run the Congress by forcing a mandatory CMS Innovation Center demonstration that will effectively change Medicare reimbursement, as the sequester cut to Part B drug reimbursement has already done.”
The American College of Rheumatology was more measured in its reaction, noting that any change in policy needs to be thoughtful in its process to ensure that patient care is not adversely affected.
“Efforts to address high costs can sometimes create significant access issues for patients while penalizing doctors for providing quality care,” ACR officials said in a statement. “These proposals include those restructuring reimbursement for Medicare Part B drugs through either flat fee payments or a competitive acquisition program, or allowing utilization management such as step therapy or ‘fail first’ protocols in the Medicare Part B program. It is imperative that policy makers stay focused on the players who control drug prices and not penalize Medicare patients who depend on timely access to needed therapies.”
The American Medical Association raised some concerns as well.
“The administration’s proposal for an International Pricing Index Model for Part B drugs raises a number of questions, and we need to have a greater understanding of the potential impact of the proposal on patients, physicians, and the health care system,” AMA President Barbara McAneny, MD, said in a statement. “We look forward to working constructively with the Administration as it seeks feedback.”
The advanced notice of proposed rulemaking was posted to the Federal Register website on Oct. 25 and is scheduled to be formally published in the publication on Oct. 30. Comments are due Dec. 24. The CMS plans to issue the proposed rule related to this model in the spring of 2019.
With site-neutral payments, the devil is in the details
Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.
In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.
The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments (HOPD) stems from physicians being underpaid in the physician fee schedule.
In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that, “while ambulatory surgical centers (ASCs) are a more efficient and lower-cost alternative to the HOPD for a number of gastroenterology procedures, it does not mean, however, that reimbursement rates for services provided in both the ASC and the HOPD should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”
The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that, while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”
The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’s proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”
The American Academy of Dermatology Association voiced its support for the proposal to the agency.
Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.
In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.
The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments (HOPD) stems from physicians being underpaid in the physician fee schedule.
In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that, “while ambulatory surgical centers (ASCs) are a more efficient and lower-cost alternative to the HOPD for a number of gastroenterology procedures, it does not mean, however, that reimbursement rates for services provided in both the ASC and the HOPD should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”
The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that, while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”
The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’s proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”
The American Academy of Dermatology Association voiced its support for the proposal to the agency.
Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.
In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.
The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments (HOPD) stems from physicians being underpaid in the physician fee schedule.
In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that, “while ambulatory surgical centers (ASCs) are a more efficient and lower-cost alternative to the HOPD for a number of gastroenterology procedures, it does not mean, however, that reimbursement rates for services provided in both the ASC and the HOPD should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”
The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that, while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”
The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’s proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”
The American Academy of Dermatology Association voiced its support for the proposal to the agency.
Study: Problems persist with APMs
Physicians continue to support advanced alternative payment models despite the fact that operational issues have not improved over the last 4 years and new ones have cropped up, according to a follow-up survey conducted by the RAND Corporation for the American Medical Association.
“All the things we heard in 2014 were still present in 2018. Both the challenges that practices had experienced back in 2014 having to do with data timeliness, data completeness and accuracy, payment model execution, all those challenges persisted,” Mark W. Friedberg, MD, senior physician policy researcher at RAND, said in an interview.
RAND surveyed 31 practices of varying practice size and specialty across six geographic regions, some of which participated in the 2014 survey. Supplemental information was provided by interviews with 32 market observers, 8 health plan leaders, 10 hospital and hospital system leaders, 10 state and local medical society leaders, and 4 chapter leaders with MGMA (formerly the Medical Group Management Association).
“We had thought we would hear that the problem had gotten a little bit better since there has been some investment in trying to tamp down the wide range of measures that are involved in these alternative payment models,” Dr. Friedberg said. “We did not see any evidence of that having any effect on the practices that participated in this study this time around.”
Indeed, concerns reported in 2014 were again reported in 2018, along with a new set of concerns, including the perceived pace of change in alternative payment models (APMs), the complexity of APMs, and physician concerns over two-sided risk models.
“Practices, especially those that participated both times, said in 2014 we had these challenges [of rapid changes in APM models] and since then, things have just gotten a lot faster,” he said, noting that doctors are complaining of models that are going through changes, sometimes without much warning. “They are changing quite rapidly from year to year. If you look at the MACRA QPP [Quality Payment Program] for example, that model changes every year to some extent and those things are hard for them to keep up with.”
Running hand in hand with the change is the complexity of the changes, a result of expanding performance measures and uncertainty with thresholds for penalties and rewards and in some ways has had little impact on improving care.
Dr. Friedberg noted that some practices are hiring people to examine APMs to devise strategic ways to choose and report data for maximum return.
“In a practice, for example, if their quality of care was already very good, what these folks ended up doing was help them choose measures and work the attribution algorithms in a strategic way to either guarantee a bonus or minimize the risk of incurring a penalty,” he said.
He also noted that practices appear to becoming more risk averse.
“We heard a lot more of the following thing, which is that if [practices] were in a two-sided risk model, several of them reported trying and succeeding in some cases offloading the downside risk to partners,” Dr. Friedberg reported. “And what this resulted in was that the practice, even though from the payer’s perspective they are in a two-sided model, the practice was actually in a one-sided model with a partner who is taking all of the downside risk and a portion of the upside risk, leaving a small upside risk proposition that remained for the practice.”
He said the range of partners that were absorbing the downside risk included hospitals, device manufacturers, consulting companies, or private equity firms.
Despite the concerns surrounding APMs, Dr. Friedberg said that “we did not hear practices broadly saying that they just weren’t interested in alternative payment models. In general, practices still remained pretty enthusiastic about these alternative payment models in theory. If they could be made simpler, if the pace of change weren’t quite so fast, that they would have a chance to really do some important care improvements in alternative payment models.”
He noted some of the surveyed practices were able to make investments in care as a direct result of participating in APMs, such as in behavioral health capabilities in primary care, for example, leading to quality of care improvements.
However, these issues could reveal a future unwillingness to participate in APMs, especially two-sided risk models, something at least the Centers for Medicare & Medicaid Services are pushing for as a stated goal of the QPP is to get practices to participate in APMs and take on more risk.
The growing aversion to taking on downside risk could lead practices to simply stay in fee for service and simply take the payment penalty because it is a fixed amount that can be planned for, as opposed to the fluctuations of bonuses and penalties that comes with a rapidly changing APM environment, Dr. Friedberg said.
Going forward, the report makes a number of recommendations to help create an environment that would potentially make APMs more successful, including simplifying the models; creating stable, predictable, and moderately paced pathways to APM participation; making data available in a more timely fashion; minimizing downside risk or helping practices better manage it; and designing APMs that will encourage clinical changes to help improve the effectiveness of care delivered.
Physicians continue to support advanced alternative payment models despite the fact that operational issues have not improved over the last 4 years and new ones have cropped up, according to a follow-up survey conducted by the RAND Corporation for the American Medical Association.
“All the things we heard in 2014 were still present in 2018. Both the challenges that practices had experienced back in 2014 having to do with data timeliness, data completeness and accuracy, payment model execution, all those challenges persisted,” Mark W. Friedberg, MD, senior physician policy researcher at RAND, said in an interview.
RAND surveyed 31 practices of varying practice size and specialty across six geographic regions, some of which participated in the 2014 survey. Supplemental information was provided by interviews with 32 market observers, 8 health plan leaders, 10 hospital and hospital system leaders, 10 state and local medical society leaders, and 4 chapter leaders with MGMA (formerly the Medical Group Management Association).
“We had thought we would hear that the problem had gotten a little bit better since there has been some investment in trying to tamp down the wide range of measures that are involved in these alternative payment models,” Dr. Friedberg said. “We did not see any evidence of that having any effect on the practices that participated in this study this time around.”
Indeed, concerns reported in 2014 were again reported in 2018, along with a new set of concerns, including the perceived pace of change in alternative payment models (APMs), the complexity of APMs, and physician concerns over two-sided risk models.
“Practices, especially those that participated both times, said in 2014 we had these challenges [of rapid changes in APM models] and since then, things have just gotten a lot faster,” he said, noting that doctors are complaining of models that are going through changes, sometimes without much warning. “They are changing quite rapidly from year to year. If you look at the MACRA QPP [Quality Payment Program] for example, that model changes every year to some extent and those things are hard for them to keep up with.”
Running hand in hand with the change is the complexity of the changes, a result of expanding performance measures and uncertainty with thresholds for penalties and rewards and in some ways has had little impact on improving care.
Dr. Friedberg noted that some practices are hiring people to examine APMs to devise strategic ways to choose and report data for maximum return.
“In a practice, for example, if their quality of care was already very good, what these folks ended up doing was help them choose measures and work the attribution algorithms in a strategic way to either guarantee a bonus or minimize the risk of incurring a penalty,” he said.
He also noted that practices appear to becoming more risk averse.
“We heard a lot more of the following thing, which is that if [practices] were in a two-sided risk model, several of them reported trying and succeeding in some cases offloading the downside risk to partners,” Dr. Friedberg reported. “And what this resulted in was that the practice, even though from the payer’s perspective they are in a two-sided model, the practice was actually in a one-sided model with a partner who is taking all of the downside risk and a portion of the upside risk, leaving a small upside risk proposition that remained for the practice.”
He said the range of partners that were absorbing the downside risk included hospitals, device manufacturers, consulting companies, or private equity firms.
Despite the concerns surrounding APMs, Dr. Friedberg said that “we did not hear practices broadly saying that they just weren’t interested in alternative payment models. In general, practices still remained pretty enthusiastic about these alternative payment models in theory. If they could be made simpler, if the pace of change weren’t quite so fast, that they would have a chance to really do some important care improvements in alternative payment models.”
He noted some of the surveyed practices were able to make investments in care as a direct result of participating in APMs, such as in behavioral health capabilities in primary care, for example, leading to quality of care improvements.
However, these issues could reveal a future unwillingness to participate in APMs, especially two-sided risk models, something at least the Centers for Medicare & Medicaid Services are pushing for as a stated goal of the QPP is to get practices to participate in APMs and take on more risk.
The growing aversion to taking on downside risk could lead practices to simply stay in fee for service and simply take the payment penalty because it is a fixed amount that can be planned for, as opposed to the fluctuations of bonuses and penalties that comes with a rapidly changing APM environment, Dr. Friedberg said.
Going forward, the report makes a number of recommendations to help create an environment that would potentially make APMs more successful, including simplifying the models; creating stable, predictable, and moderately paced pathways to APM participation; making data available in a more timely fashion; minimizing downside risk or helping practices better manage it; and designing APMs that will encourage clinical changes to help improve the effectiveness of care delivered.
Physicians continue to support advanced alternative payment models despite the fact that operational issues have not improved over the last 4 years and new ones have cropped up, according to a follow-up survey conducted by the RAND Corporation for the American Medical Association.
“All the things we heard in 2014 were still present in 2018. Both the challenges that practices had experienced back in 2014 having to do with data timeliness, data completeness and accuracy, payment model execution, all those challenges persisted,” Mark W. Friedberg, MD, senior physician policy researcher at RAND, said in an interview.
RAND surveyed 31 practices of varying practice size and specialty across six geographic regions, some of which participated in the 2014 survey. Supplemental information was provided by interviews with 32 market observers, 8 health plan leaders, 10 hospital and hospital system leaders, 10 state and local medical society leaders, and 4 chapter leaders with MGMA (formerly the Medical Group Management Association).
“We had thought we would hear that the problem had gotten a little bit better since there has been some investment in trying to tamp down the wide range of measures that are involved in these alternative payment models,” Dr. Friedberg said. “We did not see any evidence of that having any effect on the practices that participated in this study this time around.”
Indeed, concerns reported in 2014 were again reported in 2018, along with a new set of concerns, including the perceived pace of change in alternative payment models (APMs), the complexity of APMs, and physician concerns over two-sided risk models.
“Practices, especially those that participated both times, said in 2014 we had these challenges [of rapid changes in APM models] and since then, things have just gotten a lot faster,” he said, noting that doctors are complaining of models that are going through changes, sometimes without much warning. “They are changing quite rapidly from year to year. If you look at the MACRA QPP [Quality Payment Program] for example, that model changes every year to some extent and those things are hard for them to keep up with.”
Running hand in hand with the change is the complexity of the changes, a result of expanding performance measures and uncertainty with thresholds for penalties and rewards and in some ways has had little impact on improving care.
Dr. Friedberg noted that some practices are hiring people to examine APMs to devise strategic ways to choose and report data for maximum return.
“In a practice, for example, if their quality of care was already very good, what these folks ended up doing was help them choose measures and work the attribution algorithms in a strategic way to either guarantee a bonus or minimize the risk of incurring a penalty,” he said.
He also noted that practices appear to becoming more risk averse.
“We heard a lot more of the following thing, which is that if [practices] were in a two-sided risk model, several of them reported trying and succeeding in some cases offloading the downside risk to partners,” Dr. Friedberg reported. “And what this resulted in was that the practice, even though from the payer’s perspective they are in a two-sided model, the practice was actually in a one-sided model with a partner who is taking all of the downside risk and a portion of the upside risk, leaving a small upside risk proposition that remained for the practice.”
He said the range of partners that were absorbing the downside risk included hospitals, device manufacturers, consulting companies, or private equity firms.
Despite the concerns surrounding APMs, Dr. Friedberg said that “we did not hear practices broadly saying that they just weren’t interested in alternative payment models. In general, practices still remained pretty enthusiastic about these alternative payment models in theory. If they could be made simpler, if the pace of change weren’t quite so fast, that they would have a chance to really do some important care improvements in alternative payment models.”
He noted some of the surveyed practices were able to make investments in care as a direct result of participating in APMs, such as in behavioral health capabilities in primary care, for example, leading to quality of care improvements.
However, these issues could reveal a future unwillingness to participate in APMs, especially two-sided risk models, something at least the Centers for Medicare & Medicaid Services are pushing for as a stated goal of the QPP is to get practices to participate in APMs and take on more risk.
The growing aversion to taking on downside risk could lead practices to simply stay in fee for service and simply take the payment penalty because it is a fixed amount that can be planned for, as opposed to the fluctuations of bonuses and penalties that comes with a rapidly changing APM environment, Dr. Friedberg said.
Going forward, the report makes a number of recommendations to help create an environment that would potentially make APMs more successful, including simplifying the models; creating stable, predictable, and moderately paced pathways to APM participation; making data available in a more timely fashion; minimizing downside risk or helping practices better manage it; and designing APMs that will encourage clinical changes to help improve the effectiveness of care delivered.
With site-neutral payments, the devil is in the details
Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.
In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.
The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments stems from physicians being underpaid in the physician fee schedule.
The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”
The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’ proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”
The American Academy of Dermatology Association voiced its support for the proposal to the agency.
In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that reimbursement for services provided in ambulatory surgical centers and hospital outpatient departments “should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”
Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.
In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.
The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments stems from physicians being underpaid in the physician fee schedule.
The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”
The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’ proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”
The American Academy of Dermatology Association voiced its support for the proposal to the agency.
In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that reimbursement for services provided in ambulatory surgical centers and hospital outpatient departments “should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”
Physician groups are pushing back against a proposal to implement site-neutral payments, despite the fact that they generally support the concept of it.
In the proposed update to the Hospital Outpatient Prospective Payment System (OPPS) for 2019, the Centers for Medicare & Medicaid Services introduced a physician fee schedule–equivalent payment for clinic visit services when provided at an off-campus, provider-based department that is paid under the OPPS.
The American Medical Association said in a letter to the CMS that, while it “generally supports site-neutral payments, we do not believe that it is possible to sustain a high-quality health care system if site neutrality is defined as shrinking all payments to the lowest amount paid in any setting.” The AMA said that the current proposed rule is “complex, confusing, and is not truly site neutral because the policies do not apply equally to all hospital outpatient clinics,” adding that a contributor to the differential between private practice and hospital outpatient departments stems from physicians being underpaid in the physician fee schedule.
The American Academy of Family Physicians stated in a letter to Seema Verma, current administrator of the CMS, that while it supports the idea of site-neutral payments, “we note that the payment methodology for 2019 will not assure equal payments for the same service, regardless of site of service.” The AAFP noted that the goal of curbing hospital acquisition of independent physician practices may not come to fruition and that “hospitals may still be incentivized to buy physician practices based on the mix of services they provide and bill them as PBDs [provider-based departments] at Medicare rates higher than would have been paid had the practice not been bought by the hospital.”
The American College of Cardiology offered support for site-neutral payments and, while it did not come out against the CMS’ proposal, it did offer a series of recommendations to consider, including determining that payments reflect “the resources required to provide patient care in each setting” and that “payment differences across sites should be related to documented differences in the resources needed to ensure patient access and high-quality care.”
The American Academy of Dermatology Association voiced its support for the proposal to the agency.
In a letter signed by the American College of Gastroenterology, the American Gastroenterological Association, and the American Society for Gastrointestinal Endoscopy, they wrote that reimbursement for services provided in ambulatory surgical centers and hospital outpatient departments “should be the same. Our societies support payment rates appropriate for each site of service and using appropriate policy and payment levers that result in patients receiving care in the most cost-efficient site of service.”
Get your MACRA updates here at ACR 2018
MACRA! MIPS! APMs! Confused? You won’t be after a Sunday morning session at this year’s annual meeting of the American College of Rheumatology.
Zachary S. Wallace, MD, of Harvard Medical School and Massachusetts General Hospital, Boston, moderates a panel that will answer your questions about the state of the Quality Payment Program (QPP).
The session will review the updates made to the QPP for 2019 and let attendees know what tools are available to help them maximize payments under each of the tracks. The session also will provide an update on the physician-focused alternative payment model (APM) for rheumatoid arthritis that has been developed by the ACR and submitted to the Physician-Focused Payment Model Technical Advisory Committee for review. Read in depth here about the details of the ACR’s physician-focused APM as it was presented at last year’s annual meeting.
And if you don’t like what you hear about these programs, attendees will provide information on how to provide feedback to the agency to let your voice be heard when the QPP comes up for its annual update.
Sustain Your Practice: 2018 Medicare Update on MACRA and APMs
Sunday, Oct. 21, 9:00 a.m.–10:00 a.m.
MACRA! MIPS! APMs! Confused? You won’t be after a Sunday morning session at this year’s annual meeting of the American College of Rheumatology.
Zachary S. Wallace, MD, of Harvard Medical School and Massachusetts General Hospital, Boston, moderates a panel that will answer your questions about the state of the Quality Payment Program (QPP).
The session will review the updates made to the QPP for 2019 and let attendees know what tools are available to help them maximize payments under each of the tracks. The session also will provide an update on the physician-focused alternative payment model (APM) for rheumatoid arthritis that has been developed by the ACR and submitted to the Physician-Focused Payment Model Technical Advisory Committee for review. Read in depth here about the details of the ACR’s physician-focused APM as it was presented at last year’s annual meeting.
And if you don’t like what you hear about these programs, attendees will provide information on how to provide feedback to the agency to let your voice be heard when the QPP comes up for its annual update.
Sustain Your Practice: 2018 Medicare Update on MACRA and APMs
Sunday, Oct. 21, 9:00 a.m.–10:00 a.m.
MACRA! MIPS! APMs! Confused? You won’t be after a Sunday morning session at this year’s annual meeting of the American College of Rheumatology.
Zachary S. Wallace, MD, of Harvard Medical School and Massachusetts General Hospital, Boston, moderates a panel that will answer your questions about the state of the Quality Payment Program (QPP).
The session will review the updates made to the QPP for 2019 and let attendees know what tools are available to help them maximize payments under each of the tracks. The session also will provide an update on the physician-focused alternative payment model (APM) for rheumatoid arthritis that has been developed by the ACR and submitted to the Physician-Focused Payment Model Technical Advisory Committee for review. Read in depth here about the details of the ACR’s physician-focused APM as it was presented at last year’s annual meeting.
And if you don’t like what you hear about these programs, attendees will provide information on how to provide feedback to the agency to let your voice be heard when the QPP comes up for its annual update.
Sustain Your Practice: 2018 Medicare Update on MACRA and APMs
Sunday, Oct. 21, 9:00 a.m.–10:00 a.m.
REPORTING FROM THE ACR ANNUAL MEETING
MedPAC eyes ‘incident to’ billing
WASHINGTON – Should Medicare abandon “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) as part of its move away from fee-for-service payment? Some of the experts on the Medicare Payment Advisory Commission think so.
A proposal presented at a recent MedPAC meeting would eliminate “incident to” billing – a payment policy under which an APRN or PA delivers the care but the claim is filed under a physician’s National Provider Identifier (NPI) and is paid at the Medicare physician fee schedule rate. Instead, APRNs and PAs would file claims under their own NPI and be paid at 85% of the physician fee schedule rate for any claims associated with an episode of care.
About 40% of evaluation and management (E&M) office visits conducted by APRNs on established patients were likely billed “incident to” in 2016, as were about 30% of such visits performed by PAs, MedPAC staff estimated.
“To put these numbers in context, we think that the rates of ‘incident to’ billing for NPs [nurse practitioners] and PAs mean that roughly 5% of all E&M office visits billed by physicians were likely performed by an NP or PA in 2018,” Brian O’Donnell, MedPAC policy analyst, told commissioners.
One reason for eliminating “incident to” billing is that it “obscure[s] the number of services actually furnished by NPs and PAs,” Mr. O’Donnell said. “Given the rapidly expanding number of NPs and PAs, Medicare’s ‘incident to’ rules could apply to an increasing number of services.”
MedPAC commissioner Kathy Buto, former vice president of global health policy at Johnson & Johnson, expressed support for the idea but raised a red flag that the system could be manipulated so that APRN/PA claims could still be paid at 100% of the fee schedule rate.
Commissioner Bruce Pyenson, principal and consulting actuary of Milliman in New York, suggested that APRN and PA claims should be paid at 100% of the fee schedule, mirroring other Medicare efforts to achieve site-neutral payments.
Similarly, commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said that while she generally does not favor redistributing program savings, if APRN and PA claims were paid at 85%, the saving generated should go back to physicians who would otherwise lose money.
That change in revenue was a key concern for Michael Munger, MD, president of the American Academy of Family Physicians.
“We have a policy on ‘incident to’ billing at the academy,” Dr. Munger said in an interview. “It says that services that are delegated to and provided by nonphysician providers under physician supervision must be provided with the same quality and should be reimbursed at the same level as services directly provided by a physician.”
He said that lowering APRNs and PAs payments to 85% of what physicians make would impact doctors in a negative way, but if the elimination of “incident to” came with a recommendation that they be paid the same as physicians, it “would be less problematic.”
Dr. Munger described primary care as a team sport, and “this is certainly going to be felt in terms of the overall mission of delivering quality care.”
Access to care also could be reduced along with the reduced payment level, he added.
“You have to make business decisions at the end of the day,” he said. “You need to make sure that you can have adequate revenue to offset expenses, and if you are going to take a 15% cut in your revenue in, you have to look at where your expenses are, and obviously salary is your No. 1 expense. If you are not able to count on this revenue and you can’t afford to have NPs and PAs as part of the team, it is going to become an access issue for patients.”
Potential access and quality issues also resonated with the American Osteopathic Association.
“You really could see the elimination of the physician element from that practice environment and that would be to the detriment of patients,” David Pugach, AOA senior vice president of public policy, said in an interview. “Right now, you have the ability for incident billing, which requires the active participation of a physician in the management of patient care. If you end that practice, you are essentially removing the physician from the equation, and that really is an access issue; it’s a safety issue; and it’s a quality issue.”
He also noted that sometimes there is overutilization of diagnostic services with APRNs and PAs, and while costs may be saved by paying for those clinicians at less than the rate of physicians, the overutilization of other services by them could end up offsetting the savings.
“We have some significant concerns,” Mr. Pugach said.
The American Academy of Physician Assistants echoed some concerns expressed by MedPAC commissioners and staff.
“What we feel strongly about is the fact that one of the problems of ‘incident to’ is that it hides the practitioners, in this case the PA who actually renders the service,” Michael Powe, AAPA vice president of reimbursement and professional advocacy, said in an interview.
“We think that’s inappropriate for a number of reasons,” he continued. “Clearly from the issue of trying to figure who’s doing what, who saw the patient, what the quality of care happens to be, we think that PAs ought to be recognized ... and not hidden which happens under the ‘incident to’ methodology.”
He said that transparency helps determine where primary care needs are, whether they are being met, and it helps with determining network adequacy.
“So there are a number of good reasons why the accuracy and transparency should be there whether or not ‘incident to’ goes away.”
Jennifer Winter, committee chair for public education for the Society of Dermatology Physician Assistants, agreed.*
Eliminating “incident to” would grant greater visibility of PA practice “because right now, some of what we do is hidden by what the physician does” because it is billed under the physician and you can’t see what the PA is doing, especially if there is an adverse event, said Ms. Winter, who practices in Olympia, Wash. “It confounds trying to collect data on outcomes.”
She also noted that some physicians might not want to hire an NP or PA “because they can hire a physician and get 100%, but they are also going to have to pay that physician at a physician rate.”
Ms. Winter said that PAs and nurse practitioners should be getting 100% of the pay as they are doing essentially the same work that physicians would be doing.
MedPAC staffers also recommended that APRNs and PAs more clearly identify the specialty that they work in, something they do not currently have to do, to allow for more transparency and accurate data on the work that these types of clinicians are performing.
*An earlier version of this story misspelled Ms. Winter's name.
WASHINGTON – Should Medicare abandon “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) as part of its move away from fee-for-service payment? Some of the experts on the Medicare Payment Advisory Commission think so.
A proposal presented at a recent MedPAC meeting would eliminate “incident to” billing – a payment policy under which an APRN or PA delivers the care but the claim is filed under a physician’s National Provider Identifier (NPI) and is paid at the Medicare physician fee schedule rate. Instead, APRNs and PAs would file claims under their own NPI and be paid at 85% of the physician fee schedule rate for any claims associated with an episode of care.
About 40% of evaluation and management (E&M) office visits conducted by APRNs on established patients were likely billed “incident to” in 2016, as were about 30% of such visits performed by PAs, MedPAC staff estimated.
“To put these numbers in context, we think that the rates of ‘incident to’ billing for NPs [nurse practitioners] and PAs mean that roughly 5% of all E&M office visits billed by physicians were likely performed by an NP or PA in 2018,” Brian O’Donnell, MedPAC policy analyst, told commissioners.
One reason for eliminating “incident to” billing is that it “obscure[s] the number of services actually furnished by NPs and PAs,” Mr. O’Donnell said. “Given the rapidly expanding number of NPs and PAs, Medicare’s ‘incident to’ rules could apply to an increasing number of services.”
MedPAC commissioner Kathy Buto, former vice president of global health policy at Johnson & Johnson, expressed support for the idea but raised a red flag that the system could be manipulated so that APRN/PA claims could still be paid at 100% of the fee schedule rate.
Commissioner Bruce Pyenson, principal and consulting actuary of Milliman in New York, suggested that APRN and PA claims should be paid at 100% of the fee schedule, mirroring other Medicare efforts to achieve site-neutral payments.
Similarly, commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said that while she generally does not favor redistributing program savings, if APRN and PA claims were paid at 85%, the saving generated should go back to physicians who would otherwise lose money.
That change in revenue was a key concern for Michael Munger, MD, president of the American Academy of Family Physicians.
“We have a policy on ‘incident to’ billing at the academy,” Dr. Munger said in an interview. “It says that services that are delegated to and provided by nonphysician providers under physician supervision must be provided with the same quality and should be reimbursed at the same level as services directly provided by a physician.”
He said that lowering APRNs and PAs payments to 85% of what physicians make would impact doctors in a negative way, but if the elimination of “incident to” came with a recommendation that they be paid the same as physicians, it “would be less problematic.”
Dr. Munger described primary care as a team sport, and “this is certainly going to be felt in terms of the overall mission of delivering quality care.”
Access to care also could be reduced along with the reduced payment level, he added.
“You have to make business decisions at the end of the day,” he said. “You need to make sure that you can have adequate revenue to offset expenses, and if you are going to take a 15% cut in your revenue in, you have to look at where your expenses are, and obviously salary is your No. 1 expense. If you are not able to count on this revenue and you can’t afford to have NPs and PAs as part of the team, it is going to become an access issue for patients.”
Potential access and quality issues also resonated with the American Osteopathic Association.
“You really could see the elimination of the physician element from that practice environment and that would be to the detriment of patients,” David Pugach, AOA senior vice president of public policy, said in an interview. “Right now, you have the ability for incident billing, which requires the active participation of a physician in the management of patient care. If you end that practice, you are essentially removing the physician from the equation, and that really is an access issue; it’s a safety issue; and it’s a quality issue.”
He also noted that sometimes there is overutilization of diagnostic services with APRNs and PAs, and while costs may be saved by paying for those clinicians at less than the rate of physicians, the overutilization of other services by them could end up offsetting the savings.
“We have some significant concerns,” Mr. Pugach said.
The American Academy of Physician Assistants echoed some concerns expressed by MedPAC commissioners and staff.
“What we feel strongly about is the fact that one of the problems of ‘incident to’ is that it hides the practitioners, in this case the PA who actually renders the service,” Michael Powe, AAPA vice president of reimbursement and professional advocacy, said in an interview.
“We think that’s inappropriate for a number of reasons,” he continued. “Clearly from the issue of trying to figure who’s doing what, who saw the patient, what the quality of care happens to be, we think that PAs ought to be recognized ... and not hidden which happens under the ‘incident to’ methodology.”
He said that transparency helps determine where primary care needs are, whether they are being met, and it helps with determining network adequacy.
“So there are a number of good reasons why the accuracy and transparency should be there whether or not ‘incident to’ goes away.”
Jennifer Winter, committee chair for public education for the Society of Dermatology Physician Assistants, agreed.*
Eliminating “incident to” would grant greater visibility of PA practice “because right now, some of what we do is hidden by what the physician does” because it is billed under the physician and you can’t see what the PA is doing, especially if there is an adverse event, said Ms. Winter, who practices in Olympia, Wash. “It confounds trying to collect data on outcomes.”
She also noted that some physicians might not want to hire an NP or PA “because they can hire a physician and get 100%, but they are also going to have to pay that physician at a physician rate.”
Ms. Winter said that PAs and nurse practitioners should be getting 100% of the pay as they are doing essentially the same work that physicians would be doing.
MedPAC staffers also recommended that APRNs and PAs more clearly identify the specialty that they work in, something they do not currently have to do, to allow for more transparency and accurate data on the work that these types of clinicians are performing.
*An earlier version of this story misspelled Ms. Winter's name.
WASHINGTON – Should Medicare abandon “incident to” billing for advanced practice registered nurses (APRNs) and physician assistants (PAs) as part of its move away from fee-for-service payment? Some of the experts on the Medicare Payment Advisory Commission think so.
A proposal presented at a recent MedPAC meeting would eliminate “incident to” billing – a payment policy under which an APRN or PA delivers the care but the claim is filed under a physician’s National Provider Identifier (NPI) and is paid at the Medicare physician fee schedule rate. Instead, APRNs and PAs would file claims under their own NPI and be paid at 85% of the physician fee schedule rate for any claims associated with an episode of care.
About 40% of evaluation and management (E&M) office visits conducted by APRNs on established patients were likely billed “incident to” in 2016, as were about 30% of such visits performed by PAs, MedPAC staff estimated.
“To put these numbers in context, we think that the rates of ‘incident to’ billing for NPs [nurse practitioners] and PAs mean that roughly 5% of all E&M office visits billed by physicians were likely performed by an NP or PA in 2018,” Brian O’Donnell, MedPAC policy analyst, told commissioners.
One reason for eliminating “incident to” billing is that it “obscure[s] the number of services actually furnished by NPs and PAs,” Mr. O’Donnell said. “Given the rapidly expanding number of NPs and PAs, Medicare’s ‘incident to’ rules could apply to an increasing number of services.”
MedPAC commissioner Kathy Buto, former vice president of global health policy at Johnson & Johnson, expressed support for the idea but raised a red flag that the system could be manipulated so that APRN/PA claims could still be paid at 100% of the fee schedule rate.
Commissioner Bruce Pyenson, principal and consulting actuary of Milliman in New York, suggested that APRN and PA claims should be paid at 100% of the fee schedule, mirroring other Medicare efforts to achieve site-neutral payments.
Similarly, commissioner Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said that while she generally does not favor redistributing program savings, if APRN and PA claims were paid at 85%, the saving generated should go back to physicians who would otherwise lose money.
That change in revenue was a key concern for Michael Munger, MD, president of the American Academy of Family Physicians.
“We have a policy on ‘incident to’ billing at the academy,” Dr. Munger said in an interview. “It says that services that are delegated to and provided by nonphysician providers under physician supervision must be provided with the same quality and should be reimbursed at the same level as services directly provided by a physician.”
He said that lowering APRNs and PAs payments to 85% of what physicians make would impact doctors in a negative way, but if the elimination of “incident to” came with a recommendation that they be paid the same as physicians, it “would be less problematic.”
Dr. Munger described primary care as a team sport, and “this is certainly going to be felt in terms of the overall mission of delivering quality care.”
Access to care also could be reduced along with the reduced payment level, he added.
“You have to make business decisions at the end of the day,” he said. “You need to make sure that you can have adequate revenue to offset expenses, and if you are going to take a 15% cut in your revenue in, you have to look at where your expenses are, and obviously salary is your No. 1 expense. If you are not able to count on this revenue and you can’t afford to have NPs and PAs as part of the team, it is going to become an access issue for patients.”
Potential access and quality issues also resonated with the American Osteopathic Association.
“You really could see the elimination of the physician element from that practice environment and that would be to the detriment of patients,” David Pugach, AOA senior vice president of public policy, said in an interview. “Right now, you have the ability for incident billing, which requires the active participation of a physician in the management of patient care. If you end that practice, you are essentially removing the physician from the equation, and that really is an access issue; it’s a safety issue; and it’s a quality issue.”
He also noted that sometimes there is overutilization of diagnostic services with APRNs and PAs, and while costs may be saved by paying for those clinicians at less than the rate of physicians, the overutilization of other services by them could end up offsetting the savings.
“We have some significant concerns,” Mr. Pugach said.
The American Academy of Physician Assistants echoed some concerns expressed by MedPAC commissioners and staff.
“What we feel strongly about is the fact that one of the problems of ‘incident to’ is that it hides the practitioners, in this case the PA who actually renders the service,” Michael Powe, AAPA vice president of reimbursement and professional advocacy, said in an interview.
“We think that’s inappropriate for a number of reasons,” he continued. “Clearly from the issue of trying to figure who’s doing what, who saw the patient, what the quality of care happens to be, we think that PAs ought to be recognized ... and not hidden which happens under the ‘incident to’ methodology.”
He said that transparency helps determine where primary care needs are, whether they are being met, and it helps with determining network adequacy.
“So there are a number of good reasons why the accuracy and transparency should be there whether or not ‘incident to’ goes away.”
Jennifer Winter, committee chair for public education for the Society of Dermatology Physician Assistants, agreed.*
Eliminating “incident to” would grant greater visibility of PA practice “because right now, some of what we do is hidden by what the physician does” because it is billed under the physician and you can’t see what the PA is doing, especially if there is an adverse event, said Ms. Winter, who practices in Olympia, Wash. “It confounds trying to collect data on outcomes.”
She also noted that some physicians might not want to hire an NP or PA “because they can hire a physician and get 100%, but they are also going to have to pay that physician at a physician rate.”
Ms. Winter said that PAs and nurse practitioners should be getting 100% of the pay as they are doing essentially the same work that physicians would be doing.
MedPAC staffers also recommended that APRNs and PAs more clearly identify the specialty that they work in, something they do not currently have to do, to allow for more transparency and accurate data on the work that these types of clinicians are performing.
*An earlier version of this story misspelled Ms. Winter's name.
REPORTING FROM A MEDPAC MEETING
Feds say ACA’s silver plan premiums will drop in 2019
, the second-lowest cost option – the first such decline since the marketplace’s start in 2014 under the Affordable Care Act.
The Centers for Medicare & Medicaid Services reported that premiums will drop 1.5% on average, after an average increase of 25.4% in 2017 and an increase of 36.9% in 2018.
Tennessee saw the greatest reduction for the 2019 plan year, dropping 26.2%. North Dakota was at the opposite end, seeing premiums increase by 20.2%. CMS provided a state-by-state breakdown of premium changes for states in the federally facilitated marketplace.
CMS Administrator Seema Verma credits the decline to market stabilization actions taken by the agency.
“Despite predictions that our actions would increase rates and destabilize the markets, the opposite has happened,” she said in a statement. “The drop in benchmark plan premiums for plan year 2019 and the increased choices for Americans seeking insurance on the exchanges is proof positive that our actions are working.”
While the agency is “encouraged by this progress, we aren’t satisfied,” Ms. Verma added. “Even with this reduction, average rates are still too high. If we are going to truly offer affordable, high-quality health care, ultimately, the law needs to change.”
Some experts, however, were quick to dismiss Ms. Verma’s assertions that federal government action caused the decline.
In fact, the trend is more of a market correction, said Sara Collins, PhD, vice president of health coverage and access at the Commonwealth Fund, New York. It follows 2 years of premium increases by insurers anticipating government actions to intentionally destabilize the market.
“We saw a correction in premiums in 2017, which reflected the phase-out of the reinsurance program, so insurers adjusted their premiums to reflect that,” Dr. Collins said. “Also, insurers are getting to know their risk pools better. So, the prediction was that the markets would stabilize in the out-years of implementation.”
The individual market “is weathering very well the attempts by the Trump administration and Congress over the past year to weaken it,” Dr. Collins added. Those include repealing the individual mandate penalties, ending federal cost-sharing reduction payments, and promoting the sale of short-term, limited-duration health policies.
Efforts at the state level also have been helpful in stabilizing the marketplace, she noted, particularly in those states that implemented reinsurance plans. CMS noted its role in approving reinsurance waivers in seven states as a reason for the overall decline.
Matthew Fiedler, PhD, a fellow at the Brookings Institution, Washington, concurred that the reduction was more of a market correction than anything else.
It “is not that the repeal of the individual mandate and various other policy changes implemented by the administration haven’t hurt rates,” he said. “It’s that rates were far higher than they needed to be in 2018. Even with the headwind of those policy games, rates are declining this year. Without those policy changes, rates would be declining by more in 2018.”
, the second-lowest cost option – the first such decline since the marketplace’s start in 2014 under the Affordable Care Act.
The Centers for Medicare & Medicaid Services reported that premiums will drop 1.5% on average, after an average increase of 25.4% in 2017 and an increase of 36.9% in 2018.
Tennessee saw the greatest reduction for the 2019 plan year, dropping 26.2%. North Dakota was at the opposite end, seeing premiums increase by 20.2%. CMS provided a state-by-state breakdown of premium changes for states in the federally facilitated marketplace.
CMS Administrator Seema Verma credits the decline to market stabilization actions taken by the agency.
“Despite predictions that our actions would increase rates and destabilize the markets, the opposite has happened,” she said in a statement. “The drop in benchmark plan premiums for plan year 2019 and the increased choices for Americans seeking insurance on the exchanges is proof positive that our actions are working.”
While the agency is “encouraged by this progress, we aren’t satisfied,” Ms. Verma added. “Even with this reduction, average rates are still too high. If we are going to truly offer affordable, high-quality health care, ultimately, the law needs to change.”
Some experts, however, were quick to dismiss Ms. Verma’s assertions that federal government action caused the decline.
In fact, the trend is more of a market correction, said Sara Collins, PhD, vice president of health coverage and access at the Commonwealth Fund, New York. It follows 2 years of premium increases by insurers anticipating government actions to intentionally destabilize the market.
“We saw a correction in premiums in 2017, which reflected the phase-out of the reinsurance program, so insurers adjusted their premiums to reflect that,” Dr. Collins said. “Also, insurers are getting to know their risk pools better. So, the prediction was that the markets would stabilize in the out-years of implementation.”
The individual market “is weathering very well the attempts by the Trump administration and Congress over the past year to weaken it,” Dr. Collins added. Those include repealing the individual mandate penalties, ending federal cost-sharing reduction payments, and promoting the sale of short-term, limited-duration health policies.
Efforts at the state level also have been helpful in stabilizing the marketplace, she noted, particularly in those states that implemented reinsurance plans. CMS noted its role in approving reinsurance waivers in seven states as a reason for the overall decline.
Matthew Fiedler, PhD, a fellow at the Brookings Institution, Washington, concurred that the reduction was more of a market correction than anything else.
It “is not that the repeal of the individual mandate and various other policy changes implemented by the administration haven’t hurt rates,” he said. “It’s that rates were far higher than they needed to be in 2018. Even with the headwind of those policy games, rates are declining this year. Without those policy changes, rates would be declining by more in 2018.”
, the second-lowest cost option – the first such decline since the marketplace’s start in 2014 under the Affordable Care Act.
The Centers for Medicare & Medicaid Services reported that premiums will drop 1.5% on average, after an average increase of 25.4% in 2017 and an increase of 36.9% in 2018.
Tennessee saw the greatest reduction for the 2019 plan year, dropping 26.2%. North Dakota was at the opposite end, seeing premiums increase by 20.2%. CMS provided a state-by-state breakdown of premium changes for states in the federally facilitated marketplace.
CMS Administrator Seema Verma credits the decline to market stabilization actions taken by the agency.
“Despite predictions that our actions would increase rates and destabilize the markets, the opposite has happened,” she said in a statement. “The drop in benchmark plan premiums for plan year 2019 and the increased choices for Americans seeking insurance on the exchanges is proof positive that our actions are working.”
While the agency is “encouraged by this progress, we aren’t satisfied,” Ms. Verma added. “Even with this reduction, average rates are still too high. If we are going to truly offer affordable, high-quality health care, ultimately, the law needs to change.”
Some experts, however, were quick to dismiss Ms. Verma’s assertions that federal government action caused the decline.
In fact, the trend is more of a market correction, said Sara Collins, PhD, vice president of health coverage and access at the Commonwealth Fund, New York. It follows 2 years of premium increases by insurers anticipating government actions to intentionally destabilize the market.
“We saw a correction in premiums in 2017, which reflected the phase-out of the reinsurance program, so insurers adjusted their premiums to reflect that,” Dr. Collins said. “Also, insurers are getting to know their risk pools better. So, the prediction was that the markets would stabilize in the out-years of implementation.”
The individual market “is weathering very well the attempts by the Trump administration and Congress over the past year to weaken it,” Dr. Collins added. Those include repealing the individual mandate penalties, ending federal cost-sharing reduction payments, and promoting the sale of short-term, limited-duration health policies.
Efforts at the state level also have been helpful in stabilizing the marketplace, she noted, particularly in those states that implemented reinsurance plans. CMS noted its role in approving reinsurance waivers in seven states as a reason for the overall decline.
Matthew Fiedler, PhD, a fellow at the Brookings Institution, Washington, concurred that the reduction was more of a market correction than anything else.
It “is not that the repeal of the individual mandate and various other policy changes implemented by the administration haven’t hurt rates,” he said. “It’s that rates were far higher than they needed to be in 2018. Even with the headwind of those policy games, rates are declining this year. Without those policy changes, rates would be declining by more in 2018.”