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Medicare fee schedule: Proposed pay bump falls short of promise
Physicians will likely see a 0.31% uptick in their Medicare payments in 2018 and not the 0.5% promised in the Medicare Access and CHIP Reauthorization Act.
Officials at the Centers for Medicare & Medicaid Services were not able to find adequate funding in so-called misvalued codes to support the larger increase, as required by law, according to the proposed Medicare physician fee schedule for 2018.
Other provisions in the proposed Medicare physician fee schedule may be more palatable than the petite pay raise.
The proposal would roll back data reporting requirements of the Physician Quality Reporting System (PQRS), to better align them with the new Quality Payment Program (QPP), and will waive half of penalties assessed for not meeting PQRS requirements in 2016.
“We are proposing these changes based on stakeholder feedback and to better align with the MIPS [Merit-based Incentive Payment System track of the QPP] data submission requirements for the quality performance category,” according to a CMS fact sheet on the proposed fee schedule.
“This will allow some physicians who attempted to report for the 2016 performance period to avoid penalties and better align PQRS with MIPS as physicians transition to QPP,” officials from the American College of Physicians said in a statement.
Other physician organizations said they believed the proposal did not go far enough.
“While the reductions in penalties represent a move in the right direction, the [American College of Rheumatology] believes CMS should establish a value modifier adjustment of zero for 2018,” ACR officials said in a statement. “This would align with the agency’s policy to ‘zero out’ the impact of the resource use component of the Merit-based Incentive Payment System in 2019, the successor to the value modifier program. This provides additional time to continue refining the cost measures and gives physicians more time to understand the program.”
The proposed fee schedule also would delay implementation of the appropriate use criteria (AUC) for imaging services, a program that would deny payments for imaging services unless the ordering physician consulted the appropriate use criteria.
The American Medical Association “appreciates CMS’ decision to postpone the implementation of this requirement until 2019 and to make the first year an opportunity for testing and education where consultation would not be required as a condition of payment for imaging services,” according to a statement.
“We also applaud the proposed delay in implementing AUC for diagnostic imaging studies,” ACR said in its statement. “We will be gauging the readiness of our members to use clinical support systems. ... We support simplifying and phasing-in the program requirements. The ACR also strongly supports larger exemptions to the program,” such as physicians in small groups and rural and underserved areas.
The proposed fee schedule also seeks feedback from physicians and organizations on how Medicare Part B pays for biosimilars. Under the 2016 fee schedule, the average sales prices (ASPs) for all biosimilar products assigned to the same reference product are included in the same CPT code, meaning the ASPs for all biosimilars of a common reference product are used to determine a single reimbursement rate.
That CMS is looking deeper at this is being seen as a plus.
Biosimilars “tied to the same reference product may not share all indications with one another or the reference product [and] a blended payment model may cause significant confusion in a multitiered biosimilars market that may include both interchangeable and noninterchangeable products,” the Biosimilars Forum said in a statement.
The current situation “may lead to decreased physician confidence in how they are reimbursed and also dramatically reduce the investment in the development of biosimilars and thereby limit treatment options available to patients.”
Both the Biosimilars Forum and the ACR support unique codes for each biosimilar.
“Physicians can better track and monitor their effectiveness and ensure adequate pharmacovigilance in the area of biosimilars” by employing unique codes, according to ACR officials.
“AGA agrees that there should be separate, unique codes for biosimilars; however, we have additional concerns regarding gastroenterological disorders. Specifically, inflammatory bowel disease (IBD) carries unique risks with regard to immunogenicity and currently there is a paucity of clinical data for biosimilars in people with IBD. Real-world use is often the first experience in IBD for these products.”
The fee schedule proposal also would expand the Medicare Diabetes Prevention Program (DPP), currently a demonstration project, taking it nationwide in 2018. The proposal outlines the payment structure and supplier enrollment requirements and compliance standards, as well as beneficiary engagement incentives.
Physicians would be paid based on performance goals being met by patients, including meeting certain numbers of service and maintenance sessions with the program as well as achieving specific weight loss goals. For beneficiaries who are able to lose at least 5% of body weight, physicians could receive up to $810. If that weight loss goal is not achieved, the most a physician could receive is $125, according to a CMS fact sheet. Currently, DPP can be employed only via office visit; however, the proposal would allow virtual make-up sessions.
“The new proposal provides more flexibility to DPP providers in supporting patient engagement and attendance and by making performance-based payments available if patients meet weight-loss targets over longer periods of time,” according to the AMA.
The fee schedule also proposes more telemedicine coverage, specifically for counseling to discuss the need for lung cancer screening, including eligibility determination and shared decision making, as well psychotherapy for crisis, with codes for the first 60 minutes of intervention and a separate code for each additional 30 minutes. Four add-on codes have been proposed to supplement existing codes that cover interactive complexity, chronic care management services, and health risk assessment.
For clinicians providing behavioral health services, CMS is proposing an increased payment for providing face-to-face office-based services that better reflects overhead expenses.
The final rule is expected in early November.
Physicians will likely see a 0.31% uptick in their Medicare payments in 2018 and not the 0.5% promised in the Medicare Access and CHIP Reauthorization Act.
Officials at the Centers for Medicare & Medicaid Services were not able to find adequate funding in so-called misvalued codes to support the larger increase, as required by law, according to the proposed Medicare physician fee schedule for 2018.
Other provisions in the proposed Medicare physician fee schedule may be more palatable than the petite pay raise.
The proposal would roll back data reporting requirements of the Physician Quality Reporting System (PQRS), to better align them with the new Quality Payment Program (QPP), and will waive half of penalties assessed for not meeting PQRS requirements in 2016.
“We are proposing these changes based on stakeholder feedback and to better align with the MIPS [Merit-based Incentive Payment System track of the QPP] data submission requirements for the quality performance category,” according to a CMS fact sheet on the proposed fee schedule.
“This will allow some physicians who attempted to report for the 2016 performance period to avoid penalties and better align PQRS with MIPS as physicians transition to QPP,” officials from the American College of Physicians said in a statement.
Other physician organizations said they believed the proposal did not go far enough.
“While the reductions in penalties represent a move in the right direction, the [American College of Rheumatology] believes CMS should establish a value modifier adjustment of zero for 2018,” ACR officials said in a statement. “This would align with the agency’s policy to ‘zero out’ the impact of the resource use component of the Merit-based Incentive Payment System in 2019, the successor to the value modifier program. This provides additional time to continue refining the cost measures and gives physicians more time to understand the program.”
The proposed fee schedule also would delay implementation of the appropriate use criteria (AUC) for imaging services, a program that would deny payments for imaging services unless the ordering physician consulted the appropriate use criteria.
The American Medical Association “appreciates CMS’ decision to postpone the implementation of this requirement until 2019 and to make the first year an opportunity for testing and education where consultation would not be required as a condition of payment for imaging services,” according to a statement.
“We also applaud the proposed delay in implementing AUC for diagnostic imaging studies,” ACR said in its statement. “We will be gauging the readiness of our members to use clinical support systems. ... We support simplifying and phasing-in the program requirements. The ACR also strongly supports larger exemptions to the program,” such as physicians in small groups and rural and underserved areas.
The proposed fee schedule also seeks feedback from physicians and organizations on how Medicare Part B pays for biosimilars. Under the 2016 fee schedule, the average sales prices (ASPs) for all biosimilar products assigned to the same reference product are included in the same CPT code, meaning the ASPs for all biosimilars of a common reference product are used to determine a single reimbursement rate.
That CMS is looking deeper at this is being seen as a plus.
Biosimilars “tied to the same reference product may not share all indications with one another or the reference product [and] a blended payment model may cause significant confusion in a multitiered biosimilars market that may include both interchangeable and noninterchangeable products,” the Biosimilars Forum said in a statement.
The current situation “may lead to decreased physician confidence in how they are reimbursed and also dramatically reduce the investment in the development of biosimilars and thereby limit treatment options available to patients.”
Both the Biosimilars Forum and the ACR support unique codes for each biosimilar.
“Physicians can better track and monitor their effectiveness and ensure adequate pharmacovigilance in the area of biosimilars” by employing unique codes, according to ACR officials.
“AGA agrees that there should be separate, unique codes for biosimilars; however, we have additional concerns regarding gastroenterological disorders. Specifically, inflammatory bowel disease (IBD) carries unique risks with regard to immunogenicity and currently there is a paucity of clinical data for biosimilars in people with IBD. Real-world use is often the first experience in IBD for these products.”
The fee schedule proposal also would expand the Medicare Diabetes Prevention Program (DPP), currently a demonstration project, taking it nationwide in 2018. The proposal outlines the payment structure and supplier enrollment requirements and compliance standards, as well as beneficiary engagement incentives.
Physicians would be paid based on performance goals being met by patients, including meeting certain numbers of service and maintenance sessions with the program as well as achieving specific weight loss goals. For beneficiaries who are able to lose at least 5% of body weight, physicians could receive up to $810. If that weight loss goal is not achieved, the most a physician could receive is $125, according to a CMS fact sheet. Currently, DPP can be employed only via office visit; however, the proposal would allow virtual make-up sessions.
“The new proposal provides more flexibility to DPP providers in supporting patient engagement and attendance and by making performance-based payments available if patients meet weight-loss targets over longer periods of time,” according to the AMA.
The fee schedule also proposes more telemedicine coverage, specifically for counseling to discuss the need for lung cancer screening, including eligibility determination and shared decision making, as well psychotherapy for crisis, with codes for the first 60 minutes of intervention and a separate code for each additional 30 minutes. Four add-on codes have been proposed to supplement existing codes that cover interactive complexity, chronic care management services, and health risk assessment.
For clinicians providing behavioral health services, CMS is proposing an increased payment for providing face-to-face office-based services that better reflects overhead expenses.
The final rule is expected in early November.
Physicians will likely see a 0.31% uptick in their Medicare payments in 2018 and not the 0.5% promised in the Medicare Access and CHIP Reauthorization Act.
Officials at the Centers for Medicare & Medicaid Services were not able to find adequate funding in so-called misvalued codes to support the larger increase, as required by law, according to the proposed Medicare physician fee schedule for 2018.
Other provisions in the proposed Medicare physician fee schedule may be more palatable than the petite pay raise.
The proposal would roll back data reporting requirements of the Physician Quality Reporting System (PQRS), to better align them with the new Quality Payment Program (QPP), and will waive half of penalties assessed for not meeting PQRS requirements in 2016.
“We are proposing these changes based on stakeholder feedback and to better align with the MIPS [Merit-based Incentive Payment System track of the QPP] data submission requirements for the quality performance category,” according to a CMS fact sheet on the proposed fee schedule.
“This will allow some physicians who attempted to report for the 2016 performance period to avoid penalties and better align PQRS with MIPS as physicians transition to QPP,” officials from the American College of Physicians said in a statement.
Other physician organizations said they believed the proposal did not go far enough.
“While the reductions in penalties represent a move in the right direction, the [American College of Rheumatology] believes CMS should establish a value modifier adjustment of zero for 2018,” ACR officials said in a statement. “This would align with the agency’s policy to ‘zero out’ the impact of the resource use component of the Merit-based Incentive Payment System in 2019, the successor to the value modifier program. This provides additional time to continue refining the cost measures and gives physicians more time to understand the program.”
The proposed fee schedule also would delay implementation of the appropriate use criteria (AUC) for imaging services, a program that would deny payments for imaging services unless the ordering physician consulted the appropriate use criteria.
The American Medical Association “appreciates CMS’ decision to postpone the implementation of this requirement until 2019 and to make the first year an opportunity for testing and education where consultation would not be required as a condition of payment for imaging services,” according to a statement.
“We also applaud the proposed delay in implementing AUC for diagnostic imaging studies,” ACR said in its statement. “We will be gauging the readiness of our members to use clinical support systems. ... We support simplifying and phasing-in the program requirements. The ACR also strongly supports larger exemptions to the program,” such as physicians in small groups and rural and underserved areas.
The proposed fee schedule also seeks feedback from physicians and organizations on how Medicare Part B pays for biosimilars. Under the 2016 fee schedule, the average sales prices (ASPs) for all biosimilar products assigned to the same reference product are included in the same CPT code, meaning the ASPs for all biosimilars of a common reference product are used to determine a single reimbursement rate.
That CMS is looking deeper at this is being seen as a plus.
Biosimilars “tied to the same reference product may not share all indications with one another or the reference product [and] a blended payment model may cause significant confusion in a multitiered biosimilars market that may include both interchangeable and noninterchangeable products,” the Biosimilars Forum said in a statement.
The current situation “may lead to decreased physician confidence in how they are reimbursed and also dramatically reduce the investment in the development of biosimilars and thereby limit treatment options available to patients.”
Both the Biosimilars Forum and the ACR support unique codes for each biosimilar.
“Physicians can better track and monitor their effectiveness and ensure adequate pharmacovigilance in the area of biosimilars” by employing unique codes, according to ACR officials.
“AGA agrees that there should be separate, unique codes for biosimilars; however, we have additional concerns regarding gastroenterological disorders. Specifically, inflammatory bowel disease (IBD) carries unique risks with regard to immunogenicity and currently there is a paucity of clinical data for biosimilars in people with IBD. Real-world use is often the first experience in IBD for these products.”
The fee schedule proposal also would expand the Medicare Diabetes Prevention Program (DPP), currently a demonstration project, taking it nationwide in 2018. The proposal outlines the payment structure and supplier enrollment requirements and compliance standards, as well as beneficiary engagement incentives.
Physicians would be paid based on performance goals being met by patients, including meeting certain numbers of service and maintenance sessions with the program as well as achieving specific weight loss goals. For beneficiaries who are able to lose at least 5% of body weight, physicians could receive up to $810. If that weight loss goal is not achieved, the most a physician could receive is $125, according to a CMS fact sheet. Currently, DPP can be employed only via office visit; however, the proposal would allow virtual make-up sessions.
“The new proposal provides more flexibility to DPP providers in supporting patient engagement and attendance and by making performance-based payments available if patients meet weight-loss targets over longer periods of time,” according to the AMA.
The fee schedule also proposes more telemedicine coverage, specifically for counseling to discuss the need for lung cancer screening, including eligibility determination and shared decision making, as well psychotherapy for crisis, with codes for the first 60 minutes of intervention and a separate code for each additional 30 minutes. Four add-on codes have been proposed to supplement existing codes that cover interactive complexity, chronic care management services, and health risk assessment.
For clinicians providing behavioral health services, CMS is proposing an increased payment for providing face-to-face office-based services that better reflects overhead expenses.
The final rule is expected in early November.
Trump order allows end-around ACA rules
An executive order signed by President Donald J. Trump aims to expand health care coverage options, primarily for small businesses.
The order includes three key provisions.
First, it allows small businesses to band together to buy insurance collectively for their workers and allows plans to be sold across state lines, in theory extending the buying power that comes with a larger base of employees to smaller businesses.
Employers participating in association health plans “cannot exclude any employee from joining the plan and cannot develop premiums based on health condition,” according to a White House statement on the executive order.
Second, the executive order allows broader use of limited duration health insurance – short-term policies that are not intended to be comprehensive offerings and are not subject to Affordable Care Act coverage requirements.
These plans “typically feature broad provider networks and high coverage limits,” according to the White House statement. The plans are geared toward “people between jobs, people in counties with only a single insurer offering exchange plans, people with limited coverage networks, and people who missed the open enrollment period but still want insurance,” according to the executive order.
Association health plans and the short-term, limited duration insurance will not need to fully cover the ACA’s essential health benefits package; instead, they are intended to be alternatives to “expensive, mandate-laden [ACA] insurance,” according to the executive order.
Third, the order directs the secretaries of Health & Human Services, Treasury, and Labor to “explore how they can allow more businesses to use tax-free health reimbursement arrangements, or HRAs, to compensate their employees for their health care expenses,” according to the White House statement.
HRAs allow employers to cover select items, such as copayments, deductibles, and other items, that are not covered by the insurance plan offered to employees.
“With these actions, we are moving toward lower costs and more options in the health care market and taking crucial steps toward saving the American people from the nightmare of Obamacare,” President Trump said, adding that the White House will continue to put pressure on Congress to finish repeal and replace activities. He also said that Congress will be pursuing block grants, presumably for Medicaid, which he said he had the votes to accomplish.
The action taken today by the White House is already receiving pushback.
The American College of Physicians “has said repeatedly that any attempts by Congress to ‘repeal and replace’ the ACA must first do no harm to patients,” Susan Thompson Hingle, MD, chair of the American College of Physicians Board of Regents, said in a statement. “This executive order utterly fails that test.”
Under the association health plans “small employers would be allowed to purchase health plans that do not meet the ACA’s requirement to provide essential health benefits,” Dr. Hingle noted. “This means that plans would no longer have to cover medical patients needs; plans could choose not to cover pregnancy, maternity, and newborn care, or even chemotherapy. This would also mean that the ACA’s prohibition on annual and lifetime limits on coverage would no longer apply to any service an employer decides is not essential. These changes would be devastating for patients who need access to the ‘nonessential’ services, leaving them with potentially millions of dollars in out-of-pocket costs despite being insured.”
Association health plans also could further destabilize the individual market if healthy workers – who currently may have purchased coverage on the individual market – shifted to less comprehensive association health plans, leaving even fewer healthy individuals in the individual market. “Insurers will be forced to either leave the markets in droves or charge much higher premiums.”
The rules may not be able to provide the relief that President Trump has promised, according to Julius Hobson, a Washington-based health care lobbyist
“The changes that he is talking about are going to require departments and agencies to promulgate rules. They just simply can’t do that by fiat,” Mr. Hobson said in an interview. “I am not sure that we will see an immediate impact on the executive order. ... When you get down to the nitty-gritty of implementation, we could be a bit away from seeing anything that actually has impact.”
An executive order signed by President Donald J. Trump aims to expand health care coverage options, primarily for small businesses.
The order includes three key provisions.
First, it allows small businesses to band together to buy insurance collectively for their workers and allows plans to be sold across state lines, in theory extending the buying power that comes with a larger base of employees to smaller businesses.
Employers participating in association health plans “cannot exclude any employee from joining the plan and cannot develop premiums based on health condition,” according to a White House statement on the executive order.
Second, the executive order allows broader use of limited duration health insurance – short-term policies that are not intended to be comprehensive offerings and are not subject to Affordable Care Act coverage requirements.
These plans “typically feature broad provider networks and high coverage limits,” according to the White House statement. The plans are geared toward “people between jobs, people in counties with only a single insurer offering exchange plans, people with limited coverage networks, and people who missed the open enrollment period but still want insurance,” according to the executive order.
Association health plans and the short-term, limited duration insurance will not need to fully cover the ACA’s essential health benefits package; instead, they are intended to be alternatives to “expensive, mandate-laden [ACA] insurance,” according to the executive order.
Third, the order directs the secretaries of Health & Human Services, Treasury, and Labor to “explore how they can allow more businesses to use tax-free health reimbursement arrangements, or HRAs, to compensate their employees for their health care expenses,” according to the White House statement.
HRAs allow employers to cover select items, such as copayments, deductibles, and other items, that are not covered by the insurance plan offered to employees.
“With these actions, we are moving toward lower costs and more options in the health care market and taking crucial steps toward saving the American people from the nightmare of Obamacare,” President Trump said, adding that the White House will continue to put pressure on Congress to finish repeal and replace activities. He also said that Congress will be pursuing block grants, presumably for Medicaid, which he said he had the votes to accomplish.
The action taken today by the White House is already receiving pushback.
The American College of Physicians “has said repeatedly that any attempts by Congress to ‘repeal and replace’ the ACA must first do no harm to patients,” Susan Thompson Hingle, MD, chair of the American College of Physicians Board of Regents, said in a statement. “This executive order utterly fails that test.”
Under the association health plans “small employers would be allowed to purchase health plans that do not meet the ACA’s requirement to provide essential health benefits,” Dr. Hingle noted. “This means that plans would no longer have to cover medical patients needs; plans could choose not to cover pregnancy, maternity, and newborn care, or even chemotherapy. This would also mean that the ACA’s prohibition on annual and lifetime limits on coverage would no longer apply to any service an employer decides is not essential. These changes would be devastating for patients who need access to the ‘nonessential’ services, leaving them with potentially millions of dollars in out-of-pocket costs despite being insured.”
Association health plans also could further destabilize the individual market if healthy workers – who currently may have purchased coverage on the individual market – shifted to less comprehensive association health plans, leaving even fewer healthy individuals in the individual market. “Insurers will be forced to either leave the markets in droves or charge much higher premiums.”
The rules may not be able to provide the relief that President Trump has promised, according to Julius Hobson, a Washington-based health care lobbyist
“The changes that he is talking about are going to require departments and agencies to promulgate rules. They just simply can’t do that by fiat,” Mr. Hobson said in an interview. “I am not sure that we will see an immediate impact on the executive order. ... When you get down to the nitty-gritty of implementation, we could be a bit away from seeing anything that actually has impact.”
An executive order signed by President Donald J. Trump aims to expand health care coverage options, primarily for small businesses.
The order includes three key provisions.
First, it allows small businesses to band together to buy insurance collectively for their workers and allows plans to be sold across state lines, in theory extending the buying power that comes with a larger base of employees to smaller businesses.
Employers participating in association health plans “cannot exclude any employee from joining the plan and cannot develop premiums based on health condition,” according to a White House statement on the executive order.
Second, the executive order allows broader use of limited duration health insurance – short-term policies that are not intended to be comprehensive offerings and are not subject to Affordable Care Act coverage requirements.
These plans “typically feature broad provider networks and high coverage limits,” according to the White House statement. The plans are geared toward “people between jobs, people in counties with only a single insurer offering exchange plans, people with limited coverage networks, and people who missed the open enrollment period but still want insurance,” according to the executive order.
Association health plans and the short-term, limited duration insurance will not need to fully cover the ACA’s essential health benefits package; instead, they are intended to be alternatives to “expensive, mandate-laden [ACA] insurance,” according to the executive order.
Third, the order directs the secretaries of Health & Human Services, Treasury, and Labor to “explore how they can allow more businesses to use tax-free health reimbursement arrangements, or HRAs, to compensate their employees for their health care expenses,” according to the White House statement.
HRAs allow employers to cover select items, such as copayments, deductibles, and other items, that are not covered by the insurance plan offered to employees.
“With these actions, we are moving toward lower costs and more options in the health care market and taking crucial steps toward saving the American people from the nightmare of Obamacare,” President Trump said, adding that the White House will continue to put pressure on Congress to finish repeal and replace activities. He also said that Congress will be pursuing block grants, presumably for Medicaid, which he said he had the votes to accomplish.
The action taken today by the White House is already receiving pushback.
The American College of Physicians “has said repeatedly that any attempts by Congress to ‘repeal and replace’ the ACA must first do no harm to patients,” Susan Thompson Hingle, MD, chair of the American College of Physicians Board of Regents, said in a statement. “This executive order utterly fails that test.”
Under the association health plans “small employers would be allowed to purchase health plans that do not meet the ACA’s requirement to provide essential health benefits,” Dr. Hingle noted. “This means that plans would no longer have to cover medical patients needs; plans could choose not to cover pregnancy, maternity, and newborn care, or even chemotherapy. This would also mean that the ACA’s prohibition on annual and lifetime limits on coverage would no longer apply to any service an employer decides is not essential. These changes would be devastating for patients who need access to the ‘nonessential’ services, leaving them with potentially millions of dollars in out-of-pocket costs despite being insured.”
Association health plans also could further destabilize the individual market if healthy workers – who currently may have purchased coverage on the individual market – shifted to less comprehensive association health plans, leaving even fewer healthy individuals in the individual market. “Insurers will be forced to either leave the markets in droves or charge much higher premiums.”
The rules may not be able to provide the relief that President Trump has promised, according to Julius Hobson, a Washington-based health care lobbyist
“The changes that he is talking about are going to require departments and agencies to promulgate rules. They just simply can’t do that by fiat,” Mr. Hobson said in an interview. “I am not sure that we will see an immediate impact on the executive order. ... When you get down to the nitty-gritty of implementation, we could be a bit away from seeing anything that actually has impact.”
MedPAC calls for MIPS repeal
WASHINGTON – In a rare display of a near-immediate consensus, the Medicare Payment Advisory Commission agreed that the Merit-Based Incentive Payment System track of the new Quality Payment Program should be scrapped, although commission members are not yet ready to endorse a replacement plan.
MedPAC staff presented its idea of “repeal and replace” less then 10 months into the first reporting year, with staff member David V. Glass noting during an Oct. 6 meeting that “MIPS will not achieve the goal of identifying and rewarding high-value clinicians.”
“Our most basic concern is that measures used in MIPS have not been proven to be associated with high-value care,” Mr. Glass said. “Many of the MIPS quality measures are process measures, assessing only the care a provider delivers within their four walls.”
MedPAC staff proposed a replacement option affecting all clinicians who are not a part of an advanced Alternative Payment Model program. Under their proposal, Medicare would withhold 2% of each clinician’s Medicare payments. Clinicians could earn back that 2% by joining a large reporting entity (either as part of a formal business structure or something like a virtual group); they could elect to join an advanced APM, earning back the 2% and possibly bonus payments; or they could do nothing and lose the 2%.
Measurements in the proposed value program would be similar to those employed by advanced APMs in that they would be focused on population-based measures assessing clinical quality, patient experience, and value. Potential measures would address avoidable admissions/emergency department visits, mortality, readmissions, ability to obtain care, ability to communicate with clinicians, spending per beneficiary, resource use, and rates of low-value care use. Measures would be calculated based on claims.
MedPAC commissioners were nearly unanimous in their agreement to the idea of repealing MIPS but were not ready to sign off on the proposed replacement.
“I’m really concerned about the burden on physicians, and I’m concerned about some of the outlandish potential rewards for groups under MIPS that can really dissuade them from investing and moving into APMs,” commission member Paul B. Ginsburg, PhD, senior fellow in economic studies at the Brookings Institution said.
“I think we really have to get rid of MIPS and either replace it with this system, which I think has a lot of merit, or just get rid of it,” said commission member Jack Hoadley, PhD, of Georgetown University in Washington, suggesting MIPS would be “even worse” than the old Sustainable Growth Rate formula over time. It is “clear to me that MIPS is not going to ... get us toward high-value care, it is not going to make clinicians’ lives better, it is not going to make patients’ lives better, and there is a lot of money at stake.”
Commission member Dana Gelb Safran, ScD, chief performance measurement and improvement officer at Blue Cross Blue Shield of Massachusetts said she did not believe that there would be any value being gained in return for the money given to clinicians who participate in MIPS.
Not everyone was on board with the proposed replacement.
“I am very much in favor of repealing MIPS, but I don’t get the sense that we’ve gotten the replacement model quite right yet” because the proposed system does not do enough to get physicians into advanced APMs, commission member Craig Samitt, MD, chief clinical officer at Anthem, said. “So if a replacement is a voluntary model that would allow us to keep practicing health care the way we’ve been practicing, then that replacement is not a good replacement.”
The American Medical Association declined to evaluate the proposal that was laid forth by staff.
“The AMA welcomes ideas on how to improve Medicare physician payment policies,” AMA President David O. Barbe said in a statement. “We understand that MedPAC’s proposals are a work in progress, so it’s too early to render any judgment.”
Dr. Barbe noted that the AMA recommends that physicians participate in MIPS, even if it is at the lowest level simply to avoid any penalty and continue investing in the infrastructure to participate. The AMA, AGA, and other medical societies also are asking CMS to allow those who are exempt from MIPS participation to be able to opt into the program.
The American Medical Group Association (AMGA), a trade organization representing multispecialty medical groups, however, has criticized the move by CMS to increase the number of clinicians who are exempt from MIPS.
Under the proposed expansion – which would approximately double the number of clinicians who are MIPS exempt – “MIPS no longer provides really any incentive to get to value and in fact it’s a disincentive,” said Chet Speed, AMGA vice president of public policy. “That is one of the realities that MedPAC was dealing with.”
Mr. Speed emphasized that AMGA has not altered its policy on MIPS, which it wants to see enacted for all and has offered its own resources to help with the transition, but “if AMGA were to entertain a new position on MIPS, I think we probably would go with a more simple route, which is to just get rid of MIPS and repurpose the revenues that were in MIPS to APMs. ... We have not agreed upon that policy but that has been discussed internally.”
He added that “AMGA’s membership does look at MIPS as a tool that has really devolved from a value mechanism to a compliance exercise and nothing more.”
As to whether health care provider associations would come together and support the repeal of MIPS, Mr. Speed was hesitant to predict that, even though many have reservations about it, noting that it could be because the broadening of exclusions, which the AMA and most other associations support, effectively remove a lot of their membership from having to participate anyway, leaving the bigger groups such as Mayo, the Cleveland Clinic and Intermountain Healthcare to fight over a much smaller pot of bonus payments, significantly limiting the returns on investments made to be ready for the MIPS transition.
WASHINGTON – In a rare display of a near-immediate consensus, the Medicare Payment Advisory Commission agreed that the Merit-Based Incentive Payment System track of the new Quality Payment Program should be scrapped, although commission members are not yet ready to endorse a replacement plan.
MedPAC staff presented its idea of “repeal and replace” less then 10 months into the first reporting year, with staff member David V. Glass noting during an Oct. 6 meeting that “MIPS will not achieve the goal of identifying and rewarding high-value clinicians.”
“Our most basic concern is that measures used in MIPS have not been proven to be associated with high-value care,” Mr. Glass said. “Many of the MIPS quality measures are process measures, assessing only the care a provider delivers within their four walls.”
MedPAC staff proposed a replacement option affecting all clinicians who are not a part of an advanced Alternative Payment Model program. Under their proposal, Medicare would withhold 2% of each clinician’s Medicare payments. Clinicians could earn back that 2% by joining a large reporting entity (either as part of a formal business structure or something like a virtual group); they could elect to join an advanced APM, earning back the 2% and possibly bonus payments; or they could do nothing and lose the 2%.
Measurements in the proposed value program would be similar to those employed by advanced APMs in that they would be focused on population-based measures assessing clinical quality, patient experience, and value. Potential measures would address avoidable admissions/emergency department visits, mortality, readmissions, ability to obtain care, ability to communicate with clinicians, spending per beneficiary, resource use, and rates of low-value care use. Measures would be calculated based on claims.
MedPAC commissioners were nearly unanimous in their agreement to the idea of repealing MIPS but were not ready to sign off on the proposed replacement.
“I’m really concerned about the burden on physicians, and I’m concerned about some of the outlandish potential rewards for groups under MIPS that can really dissuade them from investing and moving into APMs,” commission member Paul B. Ginsburg, PhD, senior fellow in economic studies at the Brookings Institution said.
“I think we really have to get rid of MIPS and either replace it with this system, which I think has a lot of merit, or just get rid of it,” said commission member Jack Hoadley, PhD, of Georgetown University in Washington, suggesting MIPS would be “even worse” than the old Sustainable Growth Rate formula over time. It is “clear to me that MIPS is not going to ... get us toward high-value care, it is not going to make clinicians’ lives better, it is not going to make patients’ lives better, and there is a lot of money at stake.”
Commission member Dana Gelb Safran, ScD, chief performance measurement and improvement officer at Blue Cross Blue Shield of Massachusetts said she did not believe that there would be any value being gained in return for the money given to clinicians who participate in MIPS.
Not everyone was on board with the proposed replacement.
“I am very much in favor of repealing MIPS, but I don’t get the sense that we’ve gotten the replacement model quite right yet” because the proposed system does not do enough to get physicians into advanced APMs, commission member Craig Samitt, MD, chief clinical officer at Anthem, said. “So if a replacement is a voluntary model that would allow us to keep practicing health care the way we’ve been practicing, then that replacement is not a good replacement.”
The American Medical Association declined to evaluate the proposal that was laid forth by staff.
“The AMA welcomes ideas on how to improve Medicare physician payment policies,” AMA President David O. Barbe said in a statement. “We understand that MedPAC’s proposals are a work in progress, so it’s too early to render any judgment.”
Dr. Barbe noted that the AMA recommends that physicians participate in MIPS, even if it is at the lowest level simply to avoid any penalty and continue investing in the infrastructure to participate. The AMA, AGA, and other medical societies also are asking CMS to allow those who are exempt from MIPS participation to be able to opt into the program.
The American Medical Group Association (AMGA), a trade organization representing multispecialty medical groups, however, has criticized the move by CMS to increase the number of clinicians who are exempt from MIPS.
Under the proposed expansion – which would approximately double the number of clinicians who are MIPS exempt – “MIPS no longer provides really any incentive to get to value and in fact it’s a disincentive,” said Chet Speed, AMGA vice president of public policy. “That is one of the realities that MedPAC was dealing with.”
Mr. Speed emphasized that AMGA has not altered its policy on MIPS, which it wants to see enacted for all and has offered its own resources to help with the transition, but “if AMGA were to entertain a new position on MIPS, I think we probably would go with a more simple route, which is to just get rid of MIPS and repurpose the revenues that were in MIPS to APMs. ... We have not agreed upon that policy but that has been discussed internally.”
He added that “AMGA’s membership does look at MIPS as a tool that has really devolved from a value mechanism to a compliance exercise and nothing more.”
As to whether health care provider associations would come together and support the repeal of MIPS, Mr. Speed was hesitant to predict that, even though many have reservations about it, noting that it could be because the broadening of exclusions, which the AMA and most other associations support, effectively remove a lot of their membership from having to participate anyway, leaving the bigger groups such as Mayo, the Cleveland Clinic and Intermountain Healthcare to fight over a much smaller pot of bonus payments, significantly limiting the returns on investments made to be ready for the MIPS transition.
WASHINGTON – In a rare display of a near-immediate consensus, the Medicare Payment Advisory Commission agreed that the Merit-Based Incentive Payment System track of the new Quality Payment Program should be scrapped, although commission members are not yet ready to endorse a replacement plan.
MedPAC staff presented its idea of “repeal and replace” less then 10 months into the first reporting year, with staff member David V. Glass noting during an Oct. 6 meeting that “MIPS will not achieve the goal of identifying and rewarding high-value clinicians.”
“Our most basic concern is that measures used in MIPS have not been proven to be associated with high-value care,” Mr. Glass said. “Many of the MIPS quality measures are process measures, assessing only the care a provider delivers within their four walls.”
MedPAC staff proposed a replacement option affecting all clinicians who are not a part of an advanced Alternative Payment Model program. Under their proposal, Medicare would withhold 2% of each clinician’s Medicare payments. Clinicians could earn back that 2% by joining a large reporting entity (either as part of a formal business structure or something like a virtual group); they could elect to join an advanced APM, earning back the 2% and possibly bonus payments; or they could do nothing and lose the 2%.
Measurements in the proposed value program would be similar to those employed by advanced APMs in that they would be focused on population-based measures assessing clinical quality, patient experience, and value. Potential measures would address avoidable admissions/emergency department visits, mortality, readmissions, ability to obtain care, ability to communicate with clinicians, spending per beneficiary, resource use, and rates of low-value care use. Measures would be calculated based on claims.
MedPAC commissioners were nearly unanimous in their agreement to the idea of repealing MIPS but were not ready to sign off on the proposed replacement.
“I’m really concerned about the burden on physicians, and I’m concerned about some of the outlandish potential rewards for groups under MIPS that can really dissuade them from investing and moving into APMs,” commission member Paul B. Ginsburg, PhD, senior fellow in economic studies at the Brookings Institution said.
“I think we really have to get rid of MIPS and either replace it with this system, which I think has a lot of merit, or just get rid of it,” said commission member Jack Hoadley, PhD, of Georgetown University in Washington, suggesting MIPS would be “even worse” than the old Sustainable Growth Rate formula over time. It is “clear to me that MIPS is not going to ... get us toward high-value care, it is not going to make clinicians’ lives better, it is not going to make patients’ lives better, and there is a lot of money at stake.”
Commission member Dana Gelb Safran, ScD, chief performance measurement and improvement officer at Blue Cross Blue Shield of Massachusetts said she did not believe that there would be any value being gained in return for the money given to clinicians who participate in MIPS.
Not everyone was on board with the proposed replacement.
“I am very much in favor of repealing MIPS, but I don’t get the sense that we’ve gotten the replacement model quite right yet” because the proposed system does not do enough to get physicians into advanced APMs, commission member Craig Samitt, MD, chief clinical officer at Anthem, said. “So if a replacement is a voluntary model that would allow us to keep practicing health care the way we’ve been practicing, then that replacement is not a good replacement.”
The American Medical Association declined to evaluate the proposal that was laid forth by staff.
“The AMA welcomes ideas on how to improve Medicare physician payment policies,” AMA President David O. Barbe said in a statement. “We understand that MedPAC’s proposals are a work in progress, so it’s too early to render any judgment.”
Dr. Barbe noted that the AMA recommends that physicians participate in MIPS, even if it is at the lowest level simply to avoid any penalty and continue investing in the infrastructure to participate. The AMA, AGA, and other medical societies also are asking CMS to allow those who are exempt from MIPS participation to be able to opt into the program.
The American Medical Group Association (AMGA), a trade organization representing multispecialty medical groups, however, has criticized the move by CMS to increase the number of clinicians who are exempt from MIPS.
Under the proposed expansion – which would approximately double the number of clinicians who are MIPS exempt – “MIPS no longer provides really any incentive to get to value and in fact it’s a disincentive,” said Chet Speed, AMGA vice president of public policy. “That is one of the realities that MedPAC was dealing with.”
Mr. Speed emphasized that AMGA has not altered its policy on MIPS, which it wants to see enacted for all and has offered its own resources to help with the transition, but “if AMGA were to entertain a new position on MIPS, I think we probably would go with a more simple route, which is to just get rid of MIPS and repurpose the revenues that were in MIPS to APMs. ... We have not agreed upon that policy but that has been discussed internally.”
He added that “AMGA’s membership does look at MIPS as a tool that has really devolved from a value mechanism to a compliance exercise and nothing more.”
As to whether health care provider associations would come together and support the repeal of MIPS, Mr. Speed was hesitant to predict that, even though many have reservations about it, noting that it could be because the broadening of exclusions, which the AMA and most other associations support, effectively remove a lot of their membership from having to participate anyway, leaving the bigger groups such as Mayo, the Cleveland Clinic and Intermountain Healthcare to fight over a much smaller pot of bonus payments, significantly limiting the returns on investments made to be ready for the MIPS transition.
AT A MEDPAC MEETING
House, Senate committees clear CHIP reauthorization
Committees in the House and Senate passed bills to reauthorize funding for the Children’s Health Insurance Program for 5 years, but their efforts took very different paths.
Funding for CHIP expired on Sept. 30, adding a level of urgency for Congress to act.
The Senate Finance Committee needed only a voice vote during an Oct. 4 executive session, with support from both Republicans and Democrats, to move the Keeping Kids Insurance Dependable and Secure (KIDS) Act (S. 1827) to the Senate floor. The Senate version is a straight-forward bill that also extended a few childhood health demonstration projects.
Offsets in the Helping Ensure Access for Little Ones, Toddlers, and Hopeful Young by Keeping Insurance Delivery Stable (HEALTHY KIDS) Act (H.R. 3921) include means testing for Medicare Part B and D premiums by having those earning $500,000 or more on the hook for their entire Medicare Parts B and D premiums, inclusion of lottery and other lump sum awards in making Medicaid determinations, and help for states seeking to get payments from insurers.
In addition to general arguments against the use of offsets for this bill and not other measures that were also marked up during the Oct. 4 session and complaints about the inadequacy of funding for Puerto Rico’s Medicaid program in light of the recent hurricane, Energy and Commerce Committee Democrats also voiced strong objection to the use of means testing for Medicare.
“The way they are put together today will likely mean more delay and possibly no action in Congress until the end of the year as part of an omnibus appropriations bill,” Energy & Commerce Ranking Member Frank Pallone (D-N.J.) said.
Committees in the House and Senate passed bills to reauthorize funding for the Children’s Health Insurance Program for 5 years, but their efforts took very different paths.
Funding for CHIP expired on Sept. 30, adding a level of urgency for Congress to act.
The Senate Finance Committee needed only a voice vote during an Oct. 4 executive session, with support from both Republicans and Democrats, to move the Keeping Kids Insurance Dependable and Secure (KIDS) Act (S. 1827) to the Senate floor. The Senate version is a straight-forward bill that also extended a few childhood health demonstration projects.
Offsets in the Helping Ensure Access for Little Ones, Toddlers, and Hopeful Young by Keeping Insurance Delivery Stable (HEALTHY KIDS) Act (H.R. 3921) include means testing for Medicare Part B and D premiums by having those earning $500,000 or more on the hook for their entire Medicare Parts B and D premiums, inclusion of lottery and other lump sum awards in making Medicaid determinations, and help for states seeking to get payments from insurers.
In addition to general arguments against the use of offsets for this bill and not other measures that were also marked up during the Oct. 4 session and complaints about the inadequacy of funding for Puerto Rico’s Medicaid program in light of the recent hurricane, Energy and Commerce Committee Democrats also voiced strong objection to the use of means testing for Medicare.
“The way they are put together today will likely mean more delay and possibly no action in Congress until the end of the year as part of an omnibus appropriations bill,” Energy & Commerce Ranking Member Frank Pallone (D-N.J.) said.
Committees in the House and Senate passed bills to reauthorize funding for the Children’s Health Insurance Program for 5 years, but their efforts took very different paths.
Funding for CHIP expired on Sept. 30, adding a level of urgency for Congress to act.
The Senate Finance Committee needed only a voice vote during an Oct. 4 executive session, with support from both Republicans and Democrats, to move the Keeping Kids Insurance Dependable and Secure (KIDS) Act (S. 1827) to the Senate floor. The Senate version is a straight-forward bill that also extended a few childhood health demonstration projects.
Offsets in the Helping Ensure Access for Little Ones, Toddlers, and Hopeful Young by Keeping Insurance Delivery Stable (HEALTHY KIDS) Act (H.R. 3921) include means testing for Medicare Part B and D premiums by having those earning $500,000 or more on the hook for their entire Medicare Parts B and D premiums, inclusion of lottery and other lump sum awards in making Medicaid determinations, and help for states seeking to get payments from insurers.
In addition to general arguments against the use of offsets for this bill and not other measures that were also marked up during the Oct. 4 session and complaints about the inadequacy of funding for Puerto Rico’s Medicaid program in light of the recent hurricane, Energy and Commerce Committee Democrats also voiced strong objection to the use of means testing for Medicare.
“The way they are put together today will likely mean more delay and possibly no action in Congress until the end of the year as part of an omnibus appropriations bill,” Energy & Commerce Ranking Member Frank Pallone (D-N.J.) said.
SHM suggests tweaks to CMS QPP proposal
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
The Society of Hospital Medicine approves of the direction the Centers for Medicare & Medicaid Services is heading when it comes to measuring pay-for-performance for hospitalists in its Quality Payment Program (QPP) but is suggesting some tweaks to make it a better system.
The proposed CMS 2018 update to the QPP, the value-based payment scheme developed by the Medicare Access and CHIP Reauthorization Act (MACRA), included an option that would allow all physicians who primarily practice in a hospital setting to report as a unified group under the hospital umbrella – as an alternative to reporting as an individual in the Merit-Based Incentive Payment System (MIPS) track.
He said there is lot to like in that option, although there are things that need to be changed as well.
One key area SHM would like to see changed is how time spent in a hospital is measured. In the CMS proposal, codes related to site of service capture only those in the emergency room and those admitted for in-patient services. Doctors who are seeing patients on an observation basis before they are admitted are not captured and could not be included in the facility payment.
“Observation services are virtually indistinguishable from inpatient care and frequently occur on the same wards of the hospital,” SHM said in Aug. 21, 2017, comments to CMS on the proposed QPP update, noting that observational care is built around the two-midnight rule.
“We disagree with this interpretation,” the SHM letter continues. “While it is true observation is generally time limited for a given patient, practice structures and provider scheduling have a profound [impact] on the proportion of observation care an individual clinician provides.” The letter noted that hospitalists who are on observation service could have a high proportion of observation (outpatient) billing, which could in turn exclude them from qualifying for a facility-based reporting option “despite the fact they are truly hospital-based inpatient providers.”
Dr. Greeno noted that some hospitals have hospitalists that exclusively provide observational care.
The proposal designates physicians who meet a 75% threshold of providing care in an emergency room or in-patient setting as eligible to opt into facility-based reporting.
SHM suggests that if observation services cannot be included in the 75% threshold, those services should be included and “couple the calculation with a cross-check to ensure most other billing is also hospital-based. As a further check, CMS could look at specialty codes – is the provider also enrolled in Medicare as a hospitalist?” SHM also recommends lowering the threshold “to 70% or, ideally, 60%. Due to the wide variation in hospitalist practice, we are uncomfortable with the use of thresholds in general, but lowering this threshold would at least provide a kind of safety net for hospitalists who are caring for high numbers of patients on observation.”
Another key area that needs to be addressed is the quality metrics that are used for scoring, which Dr. Greeno acknowledged is “surprisingly hard to do.”
For the 2018 reporting year, CMS is proposing that the required number of measures for the MIPS program be six, that same is it currently is for 2017. While SHM agrees with this level, “we remind CMS that even six measures may be a challenge for some providers, including hospitalists, to meet. Concerted efforts should be made to ensure that those providers who have fewer than six measures available for reporting are not disadvantaged in any way.”
Two of the six hospitalist-specific quality metrics relate to heart attacks, Dr. Seymann noted.
“Most hospitalists do take care of these patients, but they can only be reported via registry or via an electronic health record, and I don’t know that all hospitalist groups have access to reporting those ways,” Dr. Seymann said. “Most folks are reporting when they submit their billing claims. That takes two measures away from them. That may significantly decrease your score, even if you are trying your best.”
While Dr. Seymann applauded CMS for the slow rollout of the MIPS program in general, “we haven’t seen great progress as far as the growth of available relevant measures for hospitalists, and I am not confident that 2 years down the line we are going to have 12 measures to choose from.”
He did suggest that hospitalists would like a greater variety of measures and want to be measured on the quality of care they provide.
“We truly believe that the majority of hospitalist groups are really heavily invested in improving the quality of care that is provided at their hospitals – that is a big part of the culture of hospital medicine in general,” Dr. Seymann said. “We want to make our ability to succeed and participate in this program as effective as we can. We want to try to minimize barriers to hospitalists hitting this one out of the park.”
SHM also noted that certain measures rarely meet the volume threshold, which could ultimately put hospitalists at a disadvantage when it comes to receiving bonus payments.
“This is not an acceptable outcome, and we strongly urge CMS to develop a solution for providers with low-volume measures, such as removing low-volume measures from the Quality category score,” SHM wrote.
Ultimately, Dr. Greeno believes the facility reporting opt-in will survive when the rule is finalized.
“We fully expect there to be a facility-based option for hospital-based doctors, including hospitalists,” he said. “So rather than reporting on physician metrics, especially metrics through MIPS, they can get rewarded or penalized based on the hospital value-based purchasing metrics for their hospital.”
MIPS: It’s time to get started
David O. Barbe, MD, is urging physicians to participate in the Medicare Quality Payment Program, even if the business case isn’t quite there.
QPP is the value-based payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA). It promotes high-value care through Medicare payment increases. But for some practices, the investment in personnel and technology needed to earn those increases may be more than the increases themselves, leading doctors to do just enough to avoid being penalized.
“I think that many physicians don’t feel they are ever going to get a bonus but sure would like to avoid a penalty,” Dr. Barbe, president of the American Medical Association, said in an exclusive interview. “I am afraid many will simply perform at the lowest level that keeps them out of the penalty. Because many of them find that making the investment it takes to perform highly, there is not a business case for that.”
Full participation in QPP’s Merit-based Incentive Payment System (MIPS) could run small practices an additional $10,000 to $30,000 a year, he said. “If you’ve got $200,000 in Medicare receipts, if you get adjusted even the maximum of 4%, that is $8,000. You can’t cover $20,000 with $8,000. The math doesn’t work. There is not a business case there for it.”
That said, Dr. Barbe still spoke in favor of QPP and noted that the AMA is working with the Centers for Medicare & Medicaid Services as well as Congress to make the program more valuable and meaningful for physicians.
“We understand where we need to go as a profession, as an industry,” he said. “How we get there is the key, it’s the challenge and it requires flexibility. ... CMS has been accommodating but there are limits to how long they can go.”
The AMA is urging doctors who have missed the 90-day window for full participation – which effectively closed for most on Oct. 2 – to consider the Pick Your Pace option offered by the CMS.
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Pick Your Pace allows physicians and practices to submit data on one measure for one patient to avoid a reduction in Medicare pay, even though they would not be eligible for a bonus.
“AMA has put out a lot of tools to help physicians assess their readiness, assess the gap between what they are able to do in their practice now and what they need to do to be successful under [the MIPS] primarily down to and including a video that would walk a physician step-by-step through the one patient, one measure, no penalty,” Dr. Barbe said.
He also encouraged doctors to pick a measure that is meaningful to their practice if only to get the ball rolling and get their feet wet in the QPP pool.
“What I tell physicians is pick something that is relevant for your practice,” he said.”If I see a lot of diabetes patients in my practice but I don’t see many people on anticoagulants, it doesn’t make sense for me to pick an anticoagulant measure.”
And if all a practice can do this year is one patient, one measure, Dr. Barbe urged physicians to look toward the next reporting year with an eye to do more, as that will ultimately lead to better quality of care delivered.
“Report on one patient and one measure this year ... but look at next year to say ‘that’s going to be a 90-day project for me,’ and get in on that. There is a pretty long laundry list of conditions and metrics that you can report on.”
And if practices start capturing relevant data, it opens the door to improving their practice if they also take the time to analyze what they are collecting.
“That is the purpose,” Dr. Barbe said. “As you measure yourself along the way, if the threshold for performance is here, and you find yourself working at this [lower] level for the first 30 days or whatever, then you stop and take stock of that” and react accordingly, whether its providing patients with a little more information about their condition or perhaps being more diligent in terms of monitoring high risk patients.
David O. Barbe, MD, is urging physicians to participate in the Medicare Quality Payment Program, even if the business case isn’t quite there.
QPP is the value-based payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA). It promotes high-value care through Medicare payment increases. But for some practices, the investment in personnel and technology needed to earn those increases may be more than the increases themselves, leading doctors to do just enough to avoid being penalized.
“I think that many physicians don’t feel they are ever going to get a bonus but sure would like to avoid a penalty,” Dr. Barbe, president of the American Medical Association, said in an exclusive interview. “I am afraid many will simply perform at the lowest level that keeps them out of the penalty. Because many of them find that making the investment it takes to perform highly, there is not a business case for that.”
Full participation in QPP’s Merit-based Incentive Payment System (MIPS) could run small practices an additional $10,000 to $30,000 a year, he said. “If you’ve got $200,000 in Medicare receipts, if you get adjusted even the maximum of 4%, that is $8,000. You can’t cover $20,000 with $8,000. The math doesn’t work. There is not a business case there for it.”
That said, Dr. Barbe still spoke in favor of QPP and noted that the AMA is working with the Centers for Medicare & Medicaid Services as well as Congress to make the program more valuable and meaningful for physicians.
“We understand where we need to go as a profession, as an industry,” he said. “How we get there is the key, it’s the challenge and it requires flexibility. ... CMS has been accommodating but there are limits to how long they can go.”
The AMA is urging doctors who have missed the 90-day window for full participation – which effectively closed for most on Oct. 2 – to consider the Pick Your Pace option offered by the CMS.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Pick Your Pace allows physicians and practices to submit data on one measure for one patient to avoid a reduction in Medicare pay, even though they would not be eligible for a bonus.
“AMA has put out a lot of tools to help physicians assess their readiness, assess the gap between what they are able to do in their practice now and what they need to do to be successful under [the MIPS] primarily down to and including a video that would walk a physician step-by-step through the one patient, one measure, no penalty,” Dr. Barbe said.
He also encouraged doctors to pick a measure that is meaningful to their practice if only to get the ball rolling and get their feet wet in the QPP pool.
“What I tell physicians is pick something that is relevant for your practice,” he said.”If I see a lot of diabetes patients in my practice but I don’t see many people on anticoagulants, it doesn’t make sense for me to pick an anticoagulant measure.”
And if all a practice can do this year is one patient, one measure, Dr. Barbe urged physicians to look toward the next reporting year with an eye to do more, as that will ultimately lead to better quality of care delivered.
“Report on one patient and one measure this year ... but look at next year to say ‘that’s going to be a 90-day project for me,’ and get in on that. There is a pretty long laundry list of conditions and metrics that you can report on.”
And if practices start capturing relevant data, it opens the door to improving their practice if they also take the time to analyze what they are collecting.
“That is the purpose,” Dr. Barbe said. “As you measure yourself along the way, if the threshold for performance is here, and you find yourself working at this [lower] level for the first 30 days or whatever, then you stop and take stock of that” and react accordingly, whether its providing patients with a little more information about their condition or perhaps being more diligent in terms of monitoring high risk patients.
David O. Barbe, MD, is urging physicians to participate in the Medicare Quality Payment Program, even if the business case isn’t quite there.
QPP is the value-based payment system created by the Medicare Access and CHIP Reauthorization Act (MACRA). It promotes high-value care through Medicare payment increases. But for some practices, the investment in personnel and technology needed to earn those increases may be more than the increases themselves, leading doctors to do just enough to avoid being penalized.
“I think that many physicians don’t feel they are ever going to get a bonus but sure would like to avoid a penalty,” Dr. Barbe, president of the American Medical Association, said in an exclusive interview. “I am afraid many will simply perform at the lowest level that keeps them out of the penalty. Because many of them find that making the investment it takes to perform highly, there is not a business case for that.”
Full participation in QPP’s Merit-based Incentive Payment System (MIPS) could run small practices an additional $10,000 to $30,000 a year, he said. “If you’ve got $200,000 in Medicare receipts, if you get adjusted even the maximum of 4%, that is $8,000. You can’t cover $20,000 with $8,000. The math doesn’t work. There is not a business case there for it.”
That said, Dr. Barbe still spoke in favor of QPP and noted that the AMA is working with the Centers for Medicare & Medicaid Services as well as Congress to make the program more valuable and meaningful for physicians.
“We understand where we need to go as a profession, as an industry,” he said. “How we get there is the key, it’s the challenge and it requires flexibility. ... CMS has been accommodating but there are limits to how long they can go.”
The AMA is urging doctors who have missed the 90-day window for full participation – which effectively closed for most on Oct. 2 – to consider the Pick Your Pace option offered by the CMS.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Pick Your Pace allows physicians and practices to submit data on one measure for one patient to avoid a reduction in Medicare pay, even though they would not be eligible for a bonus.
“AMA has put out a lot of tools to help physicians assess their readiness, assess the gap between what they are able to do in their practice now and what they need to do to be successful under [the MIPS] primarily down to and including a video that would walk a physician step-by-step through the one patient, one measure, no penalty,” Dr. Barbe said.
He also encouraged doctors to pick a measure that is meaningful to their practice if only to get the ball rolling and get their feet wet in the QPP pool.
“What I tell physicians is pick something that is relevant for your practice,” he said.”If I see a lot of diabetes patients in my practice but I don’t see many people on anticoagulants, it doesn’t make sense for me to pick an anticoagulant measure.”
And if all a practice can do this year is one patient, one measure, Dr. Barbe urged physicians to look toward the next reporting year with an eye to do more, as that will ultimately lead to better quality of care delivered.
“Report on one patient and one measure this year ... but look at next year to say ‘that’s going to be a 90-day project for me,’ and get in on that. There is a pretty long laundry list of conditions and metrics that you can report on.”
And if practices start capturing relevant data, it opens the door to improving their practice if they also take the time to analyze what they are collecting.
“That is the purpose,” Dr. Barbe said. “As you measure yourself along the way, if the threshold for performance is here, and you find yourself working at this [lower] level for the first 30 days or whatever, then you stop and take stock of that” and react accordingly, whether its providing patients with a little more information about their condition or perhaps being more diligent in terms of monitoring high risk patients.
Proposed MACRA participation threshold gets mixed reviews
Proposed changes to the Quality Payment Program (QPP) – the value-based payment program established by the Medicare Access and CHIP Reauthorization Act (MACRA) – are drawing mixed reactions from physicians.
A key component of the proposed update to the QPP is an expansion of the exemption threshold for the Merit-based Incentive Payment System (MIPS). Currently, physicians are exempt from MIPS if they bill $30,000 or less in Medicare Part B charges or have 100 or fewer Medicare patients. The proposal would increase the number of exempt physicians by raising the threshold to $90,000 or less in Part B charges or 200 or fewer Medicare patients.
Eligible clinicians and group practices that fall below the threshold can still voluntarily submit data, but they will not be scored for their participation in MIPS and will not be eligible for bonuses or face penalties for not meeting goals.
The expanded threshold proposal drew praise from the American Medical Association for exempting many small and rural practices from the requirements, but they also called on the agency to move more quickly in notifying physicians if they fall into the exempt category.
The American College of Surgeons expressed support for the changes to the threshold, adding that going forward the threshold should “be maintained at numbers no lower than that proposed for the 2018 performance period so that providers may have certainty of the criteria and their participation responsibilities from year to year.”
The American College of Cardiology supported the expansion of the low-volume threshold and encouraged the agency to review the levels annually.
But the Association of American Physicians & Surgeons suggested the volume threshold didn’t go far enough. “We ask that CMS consider a further widening of the threshold to all practices with 18 or fewer clinicians,” the group said in its comments on the proposal. “A threshold in terms of billing amounts and the number of patients creates an unhelpful incentive for physicians to turn away Medicare patients in order to qualify for the exemption.”
The group argued that larger practices can better absorb the cost of complying with MACRA regulations and basing participation on billing could create uncertainty due to fluctuations in billing from year-to-year.
Opt in option?
Several other groups sought a pathway for exempt physicians to opt into the program and take advantage of bonuses, especially those who had already prepared for the program based on the lower initial threshold.
“By raising the low-volume threshold and not offering an opt-in ability, CMS is further and needlessly delaying practices from payment based on value over volume, as well as the intent behind the establishment of virtual groups,” the American Academy of Family Physicians wrote in comments to the CMS.
The American Gastroenterological Association voiced its support for expanding the exclusion threshold and supported the idea of an opt-in, but called on the CMS to hold harmless those practices that opted in. “Clinicians and groups opting-in to the QPP should not be subject to negative payment adjustments,” AGA said in its comments to the CMS.
The American Academy of Dermatology Association supports the proposed low-volume threshold and called upon the CMS to allow those who want to participate to create a path to opt into MIPS.
The Endocrine Society supports the expansion of the threshold, but called on the CMS to provide a pathway for those who want to participate if they are otherwise excluded.
The American Osteopathic Association also called for a pathway for exempted physicians to opt in. And they cited two negative effects of expanding the threshold to a wider group of physicians. “First, it will result in wasted resources from practices that prepared for MIPS participation and are now unable to participate,” the association said in comments to the CMS. “Second, it will have the effect of dividing all practices into two levels: those that are incentivized to provide value-based care, and a significant number that are not eligible for such incentives.”
Individuals vs. groups
The American Congress of Obstetricians and Gynecologists (ACOG) supports the proposed threshold for individuals, but suggested changes for groups. “ACOG continues to believe that the threshold should only apply to individual clinicians and that CMS should develop a new, separate definition if the agency believes that groups should also have a low-volume threshold,” ACOG said in comments to the CMS. “Setting the low-volume threshold at both the individual and group level introduces unnecessary complexity into the program because other exclusions for MIPS only apply to individual clinicians.”
The Medical Group Management Association (MGMA), while supporting the general goal of reducing burden on small and solo practices, suggested it needed to be tweaked for the group setting.
“MGMA continues to question CMS’ application of the same threshold at both the clinician and group practice level,” the association said in its comments to the CMS. “This approach significantly disadvantages groups of clinicians who, in the aggregate, rarely care for Medicare patients, but include one or two members that actively participate in the program. MGMA urges CMS to extend its own logic behind setting a group practice equivalent for the non-patient-facing definition by exempting group practices when 75% or more of the national provider identifiers who bill under the group’s tax identification number meet the threshold on an individual basis.”
Expansion goes too far
But the AMGA, which represents group practices, called the new threshold “counterproductive” in its comment letter and suggested that the CMS should be lowering the threshold, not raising it.
AMGA noted that eligible clinicians who do not meet the threshold, but who are providing high-value care as defined by the QPP, are “forced to leave higher reimbursement rates on the table; these could be considerable over time.”
In addition, AMGA said that expanding the exemption decreases the money available for those who are required to participate. The CMS estimates in the proposed rule that in payment year 2019, $1.333 billion would be paid to top performers (including $500 million in exceptional performance bonus payments), but under the newest proposal, that number drops to $673 million (including $500 million in exceptional performance bonus payments). This will translate to a 0.3% bump in payment in 2020.
“The effect of eliminating of two-thirds of eligible clinicians from the MIPS formula is to financially undermine participating clinicians,” AMGA said in comments to the CMS. “They effectively lose by winning.”
Proposed changes to the Quality Payment Program (QPP) – the value-based payment program established by the Medicare Access and CHIP Reauthorization Act (MACRA) – are drawing mixed reactions from physicians.
A key component of the proposed update to the QPP is an expansion of the exemption threshold for the Merit-based Incentive Payment System (MIPS). Currently, physicians are exempt from MIPS if they bill $30,000 or less in Medicare Part B charges or have 100 or fewer Medicare patients. The proposal would increase the number of exempt physicians by raising the threshold to $90,000 or less in Part B charges or 200 or fewer Medicare patients.
Eligible clinicians and group practices that fall below the threshold can still voluntarily submit data, but they will not be scored for their participation in MIPS and will not be eligible for bonuses or face penalties for not meeting goals.
The expanded threshold proposal drew praise from the American Medical Association for exempting many small and rural practices from the requirements, but they also called on the agency to move more quickly in notifying physicians if they fall into the exempt category.
The American College of Surgeons expressed support for the changes to the threshold, adding that going forward the threshold should “be maintained at numbers no lower than that proposed for the 2018 performance period so that providers may have certainty of the criteria and their participation responsibilities from year to year.”
The American College of Cardiology supported the expansion of the low-volume threshold and encouraged the agency to review the levels annually.
But the Association of American Physicians & Surgeons suggested the volume threshold didn’t go far enough. “We ask that CMS consider a further widening of the threshold to all practices with 18 or fewer clinicians,” the group said in its comments on the proposal. “A threshold in terms of billing amounts and the number of patients creates an unhelpful incentive for physicians to turn away Medicare patients in order to qualify for the exemption.”
The group argued that larger practices can better absorb the cost of complying with MACRA regulations and basing participation on billing could create uncertainty due to fluctuations in billing from year-to-year.
Opt in option?
Several other groups sought a pathway for exempt physicians to opt into the program and take advantage of bonuses, especially those who had already prepared for the program based on the lower initial threshold.
“By raising the low-volume threshold and not offering an opt-in ability, CMS is further and needlessly delaying practices from payment based on value over volume, as well as the intent behind the establishment of virtual groups,” the American Academy of Family Physicians wrote in comments to the CMS.
The American Gastroenterological Association voiced its support for expanding the exclusion threshold and supported the idea of an opt-in, but called on the CMS to hold harmless those practices that opted in. “Clinicians and groups opting-in to the QPP should not be subject to negative payment adjustments,” AGA said in its comments to the CMS.
The American Academy of Dermatology Association supports the proposed low-volume threshold and called upon the CMS to allow those who want to participate to create a path to opt into MIPS.
The Endocrine Society supports the expansion of the threshold, but called on the CMS to provide a pathway for those who want to participate if they are otherwise excluded.
The American Osteopathic Association also called for a pathway for exempted physicians to opt in. And they cited two negative effects of expanding the threshold to a wider group of physicians. “First, it will result in wasted resources from practices that prepared for MIPS participation and are now unable to participate,” the association said in comments to the CMS. “Second, it will have the effect of dividing all practices into two levels: those that are incentivized to provide value-based care, and a significant number that are not eligible for such incentives.”
Individuals vs. groups
The American Congress of Obstetricians and Gynecologists (ACOG) supports the proposed threshold for individuals, but suggested changes for groups. “ACOG continues to believe that the threshold should only apply to individual clinicians and that CMS should develop a new, separate definition if the agency believes that groups should also have a low-volume threshold,” ACOG said in comments to the CMS. “Setting the low-volume threshold at both the individual and group level introduces unnecessary complexity into the program because other exclusions for MIPS only apply to individual clinicians.”
The Medical Group Management Association (MGMA), while supporting the general goal of reducing burden on small and solo practices, suggested it needed to be tweaked for the group setting.
“MGMA continues to question CMS’ application of the same threshold at both the clinician and group practice level,” the association said in its comments to the CMS. “This approach significantly disadvantages groups of clinicians who, in the aggregate, rarely care for Medicare patients, but include one or two members that actively participate in the program. MGMA urges CMS to extend its own logic behind setting a group practice equivalent for the non-patient-facing definition by exempting group practices when 75% or more of the national provider identifiers who bill under the group’s tax identification number meet the threshold on an individual basis.”
Expansion goes too far
But the AMGA, which represents group practices, called the new threshold “counterproductive” in its comment letter and suggested that the CMS should be lowering the threshold, not raising it.
AMGA noted that eligible clinicians who do not meet the threshold, but who are providing high-value care as defined by the QPP, are “forced to leave higher reimbursement rates on the table; these could be considerable over time.”
In addition, AMGA said that expanding the exemption decreases the money available for those who are required to participate. The CMS estimates in the proposed rule that in payment year 2019, $1.333 billion would be paid to top performers (including $500 million in exceptional performance bonus payments), but under the newest proposal, that number drops to $673 million (including $500 million in exceptional performance bonus payments). This will translate to a 0.3% bump in payment in 2020.
“The effect of eliminating of two-thirds of eligible clinicians from the MIPS formula is to financially undermine participating clinicians,” AMGA said in comments to the CMS. “They effectively lose by winning.”
Proposed changes to the Quality Payment Program (QPP) – the value-based payment program established by the Medicare Access and CHIP Reauthorization Act (MACRA) – are drawing mixed reactions from physicians.
A key component of the proposed update to the QPP is an expansion of the exemption threshold for the Merit-based Incentive Payment System (MIPS). Currently, physicians are exempt from MIPS if they bill $30,000 or less in Medicare Part B charges or have 100 or fewer Medicare patients. The proposal would increase the number of exempt physicians by raising the threshold to $90,000 or less in Part B charges or 200 or fewer Medicare patients.
Eligible clinicians and group practices that fall below the threshold can still voluntarily submit data, but they will not be scored for their participation in MIPS and will not be eligible for bonuses or face penalties for not meeting goals.
The expanded threshold proposal drew praise from the American Medical Association for exempting many small and rural practices from the requirements, but they also called on the agency to move more quickly in notifying physicians if they fall into the exempt category.
The American College of Surgeons expressed support for the changes to the threshold, adding that going forward the threshold should “be maintained at numbers no lower than that proposed for the 2018 performance period so that providers may have certainty of the criteria and their participation responsibilities from year to year.”
The American College of Cardiology supported the expansion of the low-volume threshold and encouraged the agency to review the levels annually.
But the Association of American Physicians & Surgeons suggested the volume threshold didn’t go far enough. “We ask that CMS consider a further widening of the threshold to all practices with 18 or fewer clinicians,” the group said in its comments on the proposal. “A threshold in terms of billing amounts and the number of patients creates an unhelpful incentive for physicians to turn away Medicare patients in order to qualify for the exemption.”
The group argued that larger practices can better absorb the cost of complying with MACRA regulations and basing participation on billing could create uncertainty due to fluctuations in billing from year-to-year.
Opt in option?
Several other groups sought a pathway for exempt physicians to opt into the program and take advantage of bonuses, especially those who had already prepared for the program based on the lower initial threshold.
“By raising the low-volume threshold and not offering an opt-in ability, CMS is further and needlessly delaying practices from payment based on value over volume, as well as the intent behind the establishment of virtual groups,” the American Academy of Family Physicians wrote in comments to the CMS.
The American Gastroenterological Association voiced its support for expanding the exclusion threshold and supported the idea of an opt-in, but called on the CMS to hold harmless those practices that opted in. “Clinicians and groups opting-in to the QPP should not be subject to negative payment adjustments,” AGA said in its comments to the CMS.
The American Academy of Dermatology Association supports the proposed low-volume threshold and called upon the CMS to allow those who want to participate to create a path to opt into MIPS.
The Endocrine Society supports the expansion of the threshold, but called on the CMS to provide a pathway for those who want to participate if they are otherwise excluded.
The American Osteopathic Association also called for a pathway for exempted physicians to opt in. And they cited two negative effects of expanding the threshold to a wider group of physicians. “First, it will result in wasted resources from practices that prepared for MIPS participation and are now unable to participate,” the association said in comments to the CMS. “Second, it will have the effect of dividing all practices into two levels: those that are incentivized to provide value-based care, and a significant number that are not eligible for such incentives.”
Individuals vs. groups
The American Congress of Obstetricians and Gynecologists (ACOG) supports the proposed threshold for individuals, but suggested changes for groups. “ACOG continues to believe that the threshold should only apply to individual clinicians and that CMS should develop a new, separate definition if the agency believes that groups should also have a low-volume threshold,” ACOG said in comments to the CMS. “Setting the low-volume threshold at both the individual and group level introduces unnecessary complexity into the program because other exclusions for MIPS only apply to individual clinicians.”
The Medical Group Management Association (MGMA), while supporting the general goal of reducing burden on small and solo practices, suggested it needed to be tweaked for the group setting.
“MGMA continues to question CMS’ application of the same threshold at both the clinician and group practice level,” the association said in its comments to the CMS. “This approach significantly disadvantages groups of clinicians who, in the aggregate, rarely care for Medicare patients, but include one or two members that actively participate in the program. MGMA urges CMS to extend its own logic behind setting a group practice equivalent for the non-patient-facing definition by exempting group practices when 75% or more of the national provider identifiers who bill under the group’s tax identification number meet the threshold on an individual basis.”
Expansion goes too far
But the AMGA, which represents group practices, called the new threshold “counterproductive” in its comment letter and suggested that the CMS should be lowering the threshold, not raising it.
AMGA noted that eligible clinicians who do not meet the threshold, but who are providing high-value care as defined by the QPP, are “forced to leave higher reimbursement rates on the table; these could be considerable over time.”
In addition, AMGA said that expanding the exemption decreases the money available for those who are required to participate. The CMS estimates in the proposed rule that in payment year 2019, $1.333 billion would be paid to top performers (including $500 million in exceptional performance bonus payments), but under the newest proposal, that number drops to $673 million (including $500 million in exceptional performance bonus payments). This will translate to a 0.3% bump in payment in 2020.
“The effect of eliminating of two-thirds of eligible clinicians from the MIPS formula is to financially undermine participating clinicians,” AMGA said in comments to the CMS. “They effectively lose by winning.”
Sen. Collins deals likely fatal blow to GOP’s health bill
Sen. Susan Collins (R-Maine) became the third GOP senator to confirm a no vote on the latest Republican attempt to repeal and replace the Affordable Care Act (ACA), a move that likely seals the bill’s fate.
The bill has the support of President Trump and many GOP leaders but has been roundly criticized by medical groups for insuring fewer Americans, failing to provide adequate protections for people with preexisting conditions, and barring Planned Parenthood from Medicaid participation.
“Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target,” Sen. Collins said in a Sept. 25 statement announcing her opposition to a bill sponsored by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.).
Since its introduction in mid September, the bill has undergone at least four published revisions, including providing additional funding to Maine and Alaska in an effort to flip Sen. Collins and Sen. Lisa Murkowski (R-Alaska) to the yes column. Both were no votes that helped kill a previous ACA repeal and replace effort.
“The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bill uses what could be described as a ‘give with one hand, take with the other’ distribution model” to maintain the budget neutrality of the Medicaid block grants sent to states, Sen. Collins said. “Huge Medicaid cuts down the road more than offset any short-term influx of money.”
Sen. Collins’ opposition came on the heels of a damaging analysis from the Congressional Budget Office (CBO). The preliminary analysis looked at an earlier version of the bill and found that the number of people with comprehensive health insurance would be reduced by millions and the impact would be particularly large starting in 2020, when the bill would make changes to Medicaid funding and the nongroup insurance market.
Since Senate Republicans are using the budget reconciliation process to pass this legislation, they only need 50 votes to pass the legislation, with Vice President Mike Pence providing the tie-breaking vote. But with a slim 52-seat majority, there was little margin for error. Sen. John McCain (R-Ariz.) had already announced his opposition to the Graham-Cassidy bill on Sept. 22, primarily on process grounds.
“We should not be content to pass health care legislation on a party-line basis, as Democrats did when they rammed Obamacare through Congress in 2009. If we do, our success could be as short-lived as theirs, when the political winds shift, as they regularly do,” Sen. McCain said in a statement. “The issue is too important, and too many lives are at risk, for us to leave the American people guessing from one election to the next whether and how they will acquire health insurance. A bill of this impact requires a bipartisan approach.”
He praised the work of Senate Health, Education, Labor & Pensions Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.), who have been working together on a small, focused package aimed at stabilizing the individual insurance market.
“Senators Alexander and Murray have been negotiating in good faith to fix some of the problems with Obamacare,” Sen. McCain said. “But I fear that the prospect of one last attempt at a strictly Republican bill has left the impression that their efforts cannot succeed. I hope they will resume their work should this last attempt at a partisan solution fail.”
Sen. Rand Paul (R-Ky.) also came out publicly against the Graham-Cassidy bill, though his opposition stems from it not going far enough in repealing elements of the ACA.
During a Sept. 25 Senate Finance Committee hearing on the Graham-Cassidy bill, Teresa Miller, acting secretary of the Pennsylvania Department of Human Services, testified that the real problem – the cost of health care – is getting pushed aside as everyone focuses on the coverage issue.
“This whole debate, for the last several years, has been about coverage and we haven’t been talking about the cost of health care,” Ms. Miller told the committee. “At the end of the day, insurance is a reflection of the cost of health care. So if we don’t have a debate in this county and discussion about how we get at the underlying cost of care, we have a major problem. That’s really the debate we should be having.”
Senate Majority Leader Mitch McConnell (R-Ky.) has not signaled whether he would still bring Graham-Cassidy to a vote, given that it appears not to have the votes needed for passage. If he chooses to move forward with the bill, the vote would need to happen before the end of the day on Sept. 30 to use the budget reconciliation process and gain passage with a simple majority.
Sen. Susan Collins (R-Maine) became the third GOP senator to confirm a no vote on the latest Republican attempt to repeal and replace the Affordable Care Act (ACA), a move that likely seals the bill’s fate.
The bill has the support of President Trump and many GOP leaders but has been roundly criticized by medical groups for insuring fewer Americans, failing to provide adequate protections for people with preexisting conditions, and barring Planned Parenthood from Medicaid participation.
“Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target,” Sen. Collins said in a Sept. 25 statement announcing her opposition to a bill sponsored by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.).
Since its introduction in mid September, the bill has undergone at least four published revisions, including providing additional funding to Maine and Alaska in an effort to flip Sen. Collins and Sen. Lisa Murkowski (R-Alaska) to the yes column. Both were no votes that helped kill a previous ACA repeal and replace effort.
“The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bill uses what could be described as a ‘give with one hand, take with the other’ distribution model” to maintain the budget neutrality of the Medicaid block grants sent to states, Sen. Collins said. “Huge Medicaid cuts down the road more than offset any short-term influx of money.”
Sen. Collins’ opposition came on the heels of a damaging analysis from the Congressional Budget Office (CBO). The preliminary analysis looked at an earlier version of the bill and found that the number of people with comprehensive health insurance would be reduced by millions and the impact would be particularly large starting in 2020, when the bill would make changes to Medicaid funding and the nongroup insurance market.
Since Senate Republicans are using the budget reconciliation process to pass this legislation, they only need 50 votes to pass the legislation, with Vice President Mike Pence providing the tie-breaking vote. But with a slim 52-seat majority, there was little margin for error. Sen. John McCain (R-Ariz.) had already announced his opposition to the Graham-Cassidy bill on Sept. 22, primarily on process grounds.
“We should not be content to pass health care legislation on a party-line basis, as Democrats did when they rammed Obamacare through Congress in 2009. If we do, our success could be as short-lived as theirs, when the political winds shift, as they regularly do,” Sen. McCain said in a statement. “The issue is too important, and too many lives are at risk, for us to leave the American people guessing from one election to the next whether and how they will acquire health insurance. A bill of this impact requires a bipartisan approach.”
He praised the work of Senate Health, Education, Labor & Pensions Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.), who have been working together on a small, focused package aimed at stabilizing the individual insurance market.
“Senators Alexander and Murray have been negotiating in good faith to fix some of the problems with Obamacare,” Sen. McCain said. “But I fear that the prospect of one last attempt at a strictly Republican bill has left the impression that their efforts cannot succeed. I hope they will resume their work should this last attempt at a partisan solution fail.”
Sen. Rand Paul (R-Ky.) also came out publicly against the Graham-Cassidy bill, though his opposition stems from it not going far enough in repealing elements of the ACA.
During a Sept. 25 Senate Finance Committee hearing on the Graham-Cassidy bill, Teresa Miller, acting secretary of the Pennsylvania Department of Human Services, testified that the real problem – the cost of health care – is getting pushed aside as everyone focuses on the coverage issue.
“This whole debate, for the last several years, has been about coverage and we haven’t been talking about the cost of health care,” Ms. Miller told the committee. “At the end of the day, insurance is a reflection of the cost of health care. So if we don’t have a debate in this county and discussion about how we get at the underlying cost of care, we have a major problem. That’s really the debate we should be having.”
Senate Majority Leader Mitch McConnell (R-Ky.) has not signaled whether he would still bring Graham-Cassidy to a vote, given that it appears not to have the votes needed for passage. If he chooses to move forward with the bill, the vote would need to happen before the end of the day on Sept. 30 to use the budget reconciliation process and gain passage with a simple majority.
Sen. Susan Collins (R-Maine) became the third GOP senator to confirm a no vote on the latest Republican attempt to repeal and replace the Affordable Care Act (ACA), a move that likely seals the bill’s fate.
The bill has the support of President Trump and many GOP leaders but has been roundly criticized by medical groups for insuring fewer Americans, failing to provide adequate protections for people with preexisting conditions, and barring Planned Parenthood from Medicaid participation.
“Sweeping reforms to our health care system and to Medicaid can’t be done well in a compressed time frame, especially when the actual bill is a moving target,” Sen. Collins said in a Sept. 25 statement announcing her opposition to a bill sponsored by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.).
Since its introduction in mid September, the bill has undergone at least four published revisions, including providing additional funding to Maine and Alaska in an effort to flip Sen. Collins and Sen. Lisa Murkowski (R-Alaska) to the yes column. Both were no votes that helped kill a previous ACA repeal and replace effort.
“The fact is, Maine still loses money under whichever version of the Graham-Cassidy bill we consider because the bill uses what could be described as a ‘give with one hand, take with the other’ distribution model” to maintain the budget neutrality of the Medicaid block grants sent to states, Sen. Collins said. “Huge Medicaid cuts down the road more than offset any short-term influx of money.”
Sen. Collins’ opposition came on the heels of a damaging analysis from the Congressional Budget Office (CBO). The preliminary analysis looked at an earlier version of the bill and found that the number of people with comprehensive health insurance would be reduced by millions and the impact would be particularly large starting in 2020, when the bill would make changes to Medicaid funding and the nongroup insurance market.
Since Senate Republicans are using the budget reconciliation process to pass this legislation, they only need 50 votes to pass the legislation, with Vice President Mike Pence providing the tie-breaking vote. But with a slim 52-seat majority, there was little margin for error. Sen. John McCain (R-Ariz.) had already announced his opposition to the Graham-Cassidy bill on Sept. 22, primarily on process grounds.
“We should not be content to pass health care legislation on a party-line basis, as Democrats did when they rammed Obamacare through Congress in 2009. If we do, our success could be as short-lived as theirs, when the political winds shift, as they regularly do,” Sen. McCain said in a statement. “The issue is too important, and too many lives are at risk, for us to leave the American people guessing from one election to the next whether and how they will acquire health insurance. A bill of this impact requires a bipartisan approach.”
He praised the work of Senate Health, Education, Labor & Pensions Committee Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Murray (D-Wash.), who have been working together on a small, focused package aimed at stabilizing the individual insurance market.
“Senators Alexander and Murray have been negotiating in good faith to fix some of the problems with Obamacare,” Sen. McCain said. “But I fear that the prospect of one last attempt at a strictly Republican bill has left the impression that their efforts cannot succeed. I hope they will resume their work should this last attempt at a partisan solution fail.”
Sen. Rand Paul (R-Ky.) also came out publicly against the Graham-Cassidy bill, though his opposition stems from it not going far enough in repealing elements of the ACA.
During a Sept. 25 Senate Finance Committee hearing on the Graham-Cassidy bill, Teresa Miller, acting secretary of the Pennsylvania Department of Human Services, testified that the real problem – the cost of health care – is getting pushed aside as everyone focuses on the coverage issue.
“This whole debate, for the last several years, has been about coverage and we haven’t been talking about the cost of health care,” Ms. Miller told the committee. “At the end of the day, insurance is a reflection of the cost of health care. So if we don’t have a debate in this county and discussion about how we get at the underlying cost of care, we have a major problem. That’s really the debate we should be having.”
Senate Majority Leader Mitch McConnell (R-Ky.) has not signaled whether he would still bring Graham-Cassidy to a vote, given that it appears not to have the votes needed for passage. If he chooses to move forward with the bill, the vote would need to happen before the end of the day on Sept. 30 to use the budget reconciliation process and gain passage with a simple majority.
Docs, insurers condemn latest ‘repeal and replace’ plan
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
AGA is also concerned that there are no guarantees that states have to provide essential benefits, patients that gained coverage through the ACA would lose that coverage, and most importantly, patients with pre-existing conditions have no guarantee that they will continue to receive affordable coverage.
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
AGA is also concerned that there are no guarantees that states have to provide essential benefits, patients that gained coverage through the ACA would lose that coverage, and most importantly, patients with pre-existing conditions have no guarantee that they will continue to receive affordable coverage.
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
AGA is also concerned that there are no guarantees that states have to provide essential benefits, patients that gained coverage through the ACA would lose that coverage, and most importantly, patients with pre-existing conditions have no guarantee that they will continue to receive affordable coverage.
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Docs, insurers condemn latest ‘repeal and replace’ plan
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.
Medical societies and insurers are voicing their opposition to legislation that would alter provisions of the Affordable Care Act and fundamentally change how Medicaid is funded.
The bill, introduced by Sen. Lindsey Graham (R-S.C.), Sen. Bill Cassidy (R-La.), Sen. Dean Heller (R-Nev.), and Sen. Ron Johnson (R-Wis.), features a number of provisions long sought by the GOP, including the repeal of the individual and employer mandates, repeal of individual tax credits as of 2020, and repeal of the medical device tax. The bill also would promote the use of health savings accounts and turn Medicaid funding into a block grant program, allowing states to implement policies such as work requirements.
James L. Madara, MD, CEO of the American Medical Association, told congressional leaders in a Sept. 19 letter that the bill would violate the precept of “first do no harm” and results in millions of Americans losing their health coverage. Additionally, it would destabilize health insurance markets and decrease access to affordable coverage.
“We are also concerned that the proposal would convert the Medicaid program into a system that limits federal support to care for needy patients to an insufficient predetermined formula based on per capita caps,” Dr. Madara continued. “Per capita caps fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation. In addition, the amendment does not take steps toward coverage and access for all Americans, and while insurers are still required to offer coverage to patients with preexisting conditions, allowing states to get waivers to vary premiums based on health status would allow insurers to charge unaffordable premiums based on those preexisting conditions. Also, waivers of essential health benefits will mean patients may not have access to coverage for services pertinent to treating their conditions.”
The American Congress of Obstetricians and Gynecologists called the bill an “assault on women’s health.” The bill would end guaranteed insurance coverage of maternity care and women’s health preventive services, including cancer screenings and contraception, ACOG president Haywood Brown, MD, said in a statement.
Dr. Brown added that the bill “jeopardizes access to care for women with high-risk and expensive pregnancies, such as those with Zika virus, opioid use disorder, and preeclampsia. It further obstructs safety net patients’ access to care by forbidding Planned Parenthood’s participation in the Medicaid program.”
Doctors aren’t the only ones objecting to the GOP legislation. America’s Health Insurance Plans president and CEO Marilyn Tavenner said in a Sept. 20 letter to Congress that the bill would further destabilize the individual health insurance market.
The bill’s road to passage is far from certain. Once again, the GOP is aiming to use the budget reconciliation process to pass this legislation, which means it needs only a simple majority to pass (a minimum of 50 votes with Vice President Mike Pence offering the tiebreaker if the bill cannot get 51 votes). But even getting to 50 votes is going to be a challenge as the last attempt to pass similar repeal and replace language failed when Sen. Susan Collins (R-Maine), Sen. Lisa Murkowski (R-Alaska), and Sen. John McCain (R-Ariz.) voted that package down. Given the similar features, Sen. Collins and Sen. Murkowski may still oppose the bill, while Sen. Rand Paul (R-Ky.) has been vocal about his displeasure with the bill and other GOP senators are getting pressure from their state governors to oppose the bill.
The Senate Finance Committee has scheduled a Sept. 25 hearing to consider the bill, but as of press time, no witnesses have been announced, and the bill likely will not follow the regular order of allowing for amendments by committee members prior to its introduction on the Senate floor later that week.
Based on current budget rules, the bill must be passed by Sept. 30 in order for the budget reconciliation process to be used and to allow for passage with a simple majority. If the Senate is able to pass the bill, House Speaker Paul Ryan (R-Wisc.) has said he will bring it up in the House. President Trump has indicated he will sign it into law if it reaches his desk.