Public Policy

Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.

Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?

Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”

Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.

“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”

What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.

In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.

However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”

MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.

The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.

“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.¹

CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.

“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”

However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.

“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.

At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.² However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.

He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.

As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”

However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.³ It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.

Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.

“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
 

References

1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.

2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.

3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
 

Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.

Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?

Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”

Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.

“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”

What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.

In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.

However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”

MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.

The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.

“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.¹

CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.

“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”

However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.

“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.

At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.² However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.

He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.

As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”

However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.³ It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.

Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.

“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
 

References

1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.

2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.

3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
 

Come November 2018, Americans will return to the polls to vote for their representatives in Congress, for governors, and for state legislative seats.

Health care has been a topic of debate since the 2016 elections brought a Republican sweep to the executive and legislative branches, but other issues have since moved to the forefront. Will the midterm elections this year prove health care to be a significant issue at the polls?

Unlikely, said Robert Berenson, MD, FACP, Institute Fellow of the Health Policy Center at the Urban Institute. More likely, the election will be a referendum on President Donald Trump, he said. “Things are so partisan right now and it’s all about Trump. I don’t see serious discussion about health policy.”

Ron Greeno, MD, MHM, FCCP, immediate past president of SHM and former chair of the Public Policy Committee, also doesn’t see health care rising to the top of election year issues. But that doesn’t mean health care doesn’t matter to American voters.

“Whether Democrats control the House or Republicans control the House won’t likely make a big difference in terms of impact on the things we care about,” said Dr. Greeno. “The issues they debate in Washington are not going to save the health care system. They are just debating about who is going to pay for what and for whom. To save our health care system, we have to lower the cost of care and only providers can do that.”

What the government can do, he said, is create the right incentives for providers to move away from fee for service and participate in new models that may lower the cost of care. At the same time, “the economy also has to grow at a robust pace, which will make a huge difference. So, recent increases in economic growth rate are welcomed,” said Dr. Greeno.

In 2015, Republicans and Democrats came together to pass bipartisan legislation aimed at moving the health care system away from fee for service: the Medicare and CHIP Reauthorization Act, or MACRA.

However, the law has not been without frustrations, and these concerns will likely not be part of any candidate campaigns in 2018, Dr. Greeno predicted: “There’s not a lot of appetite to reopen the statute (more than) 2 years after it passed.”

MACRA provides clinicians two pathways to reimbursement. The first track, called MIPS (Merit-Based Incentive Payment System), bases a portion of physician reimbursement on scores measured across several categories, including cost and quality. It still operates largely under a fee-for-service framework but is meant to be budget neutral; for every winner there is a loser.

The second track, called the APMs (Alternative Payment Models), requires physicians to take on substantial risk (with potential for reward), if they can achieve specific patient volumes under approved models. However, few providers qualify, especially among hospitalists, though the structure of the program makes it clear that the Centers for Medicare & Medicaid Services intends to have most providers ultimately transition to APMs.

“There’s growing recognition that MACRA, at least the MIPS portion, was a big mistake but Congress can’t go back and say we blew it,” Dr. Berenson said. “CMS has now exempted somewhere between 550,000 and 900,000 clinicians from MACRA,” because they cannot meet the requirements of either pathway without significant hardship.¹

CMS wasn’t considering hospitalists specifically when implementing the law, though hospitalists admit half of the Medicare patients in the United States, Dr. Greeno said. There are very few hospitalists currently participating in Advanced APMs and those that are, do not see the volume of patients the pathway requires.

“What hospitalists do is very conducive to alternative payment models, and we can help those alternative payment models drive improved quality and lowered costs,” said Dr. Greeno. “Hospitals use hospitalists to help them manage risk, so it’s frustrating that most hospitalists will not meet the thresholds for the APM track and benefit from the incentives created.”

However, the Society of Hospital Medicine continues to work on behalf of hospitalists. Thanks to its efforts, Dr. Greeno explained, CMS is planning in 2019 to allow hospitalists to choose to be scored under MIPS based on their hospital’s performance across reporting categories. Or, they can choose to report on their own and opt out of this new “facility-based” option.

“We are working with (CMS) to figure out how to make this new option work,” said Dr. Greeno.

At the state level, 36 governorships are up for grabs and those outcomes could influence the direction of Medicaid. In Kentucky, the Trump administration approved a waiver allowing the state to enforce work requirements for Medicaid recipients. However, on June 29, 2018, the D.C. federal district court invalidated the Kentucky HEALTH waiver approval (with the exception of Kentucky’s IMD SUD [institutions for mental disease for substance use disorders] payment waiver authority) and sent it back to HHS to reconsider. Ten other states as of August 2018 had applied for similar waivers.² However, Dr. Berenson believes that most of what could happen to Medicaid will be a topic after the midterm elections and not before.

He also believes drug prices could become an issue in national elections, though there will not be an easy solution from either side. “Democrats will be reluctant to say they’re going to negotiate drug prices; they’re going to want the government to negotiate for Medicare-like pricing.” Republicans, on the other hand, will be reluctant to consider government regulation.

As a general principle leading into the midterms: “Democrats want to avoid an internal war about whether they are for Medicare for all or single payer or not,” Dr. Berenson said. “What I’m hoping doesn’t happen is that it becomes a litmus test for purity where you have to be for single payer. I think would be huge mistake because it’s not realistic that it would ever get there.”

However, he cites an idea from left-leaning Princeton University’s Paul Starr, a professor of sociology and public affairs, that Democrats could consider: so-called Midlife Medicare, an option that could be made available to Americans beginning at age 50 years.³ It would represent a new Medicare option, funded by general revenues and premiums, available to people age 50 years and older and those younger than 65 years who are without employer-sponsored health insurance.

Regardless, as the United States catapults toward another election that could disrupt the political system or maintain the relative status quo, Dr. Greeno said hospitalists continue to play key roles in improving American health care.

“There are programs in place where we can get the job done if we in the provider community are creative and participative,” he said. “Some of the most important work being done is coming out of the CMS Innovation Center. Hospitalists continue to be a big part of that, but we knew it would take decades of really hard work and I don’t see anything happening in the midterms to derail this or bring about a massive increase in the pace of change.”
 

References

1. Dickson V. CMS gives more small practices a pass on MACRA. Modern Healthcare. Published June 20, 2017.

2. Medicaid Waiver Tracker: Which States Have Approved and Pending Section 1115 Medicaid Waivers? Kaiser Family Foundation. Published Aug. 8, 2018.

3. Starr P. A new strategy for health care. The American Prospect. Published Jan. 4, 2018. Accessed March 5, 2018.
 

Recommendations on potential physician-focused alternative payment models so far have gained little traction with officials at the Centers for Medicare & Medicaid Services, but that could be changing.

TheaDesign/Thinkstock

At a recent meeting of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), Alex Azar, secretary of the Department of Health & Human Services, and Seema Verma, administrator of the Centers for Medicare & Medicaid Services, attended briefly, according to officials at the American College of Emergency Physicians. ACEP was having its proposal evaluated by PTAC.

Physician organizations have been puzzled as to why federal health officials have yet to approve a physician-developed alternative payment model (APM) under the Quality Payment Program, despite several being recommended by PTAC. In fact, no physician-developed APM has even been sent to the Center for Medicare and Medicaid Innovation for further testing and refinement.

ACEP’s model, the Acute Unscheduled Care Model, “provides incentives to safely discharge Medicare beneficiaries from the ED by facilitating and rewarding postdischarge care coordination,” the organizations notes in the model description submitted to PTAC. “The model ensures that emergency physicians who make the decision to provide safe, efficient outpatient care have the necessary tools to support this transformation and are rewarded for their decision making.”

Going into the meeting, the preliminary evaluation report had the PTAC reviewers agreeing unanimously that the model met 7 of the secretary’s 10 criteria for a physician-focused APM, that the majority agreed on the 8th criterion, and a majority agreed that the model did not meet criteria on the remaining two items.

PTAC reviewers “thought that we met all 10 criteria for models that the secretary put forth for evaluating physician-focused payment models,” Jeffrey Davis, ACEP Director of Regulatory Affairs, said in an interview, adding that the attendance of Mr. Azar and Ms. Verma at the meeting was a positive development.

“I think we were especially inspired by the fact that Secretary Azar, Administrator Verma, and Adam Boehler, the new head of [Center for Medicare and Medicaid Innovation], spoke at the beginning of the PTAC meeting,” he said, adding that while no models have been formally implemented or even designated for testing, they said that ideas are being incorporated into model development going on at the CMS.

Ms. Verma went so far as to tweet that “this group of leading experts volunteer their time to improve our healthcare system, and we greatly value their input.”

“We still think [PTAC] is a great avenue to get our model into the public arena,” Mr. Davis said. “We are optimistic.”

[email protected]

Recommendations on potential physician-focused alternative payment models so far have gained little traction with officials at the Centers for Medicare & Medicaid Services, but that could be changing.

TheaDesign/Thinkstock

At a recent meeting of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), Alex Azar, secretary of the Department of Health & Human Services, and Seema Verma, administrator of the Centers for Medicare & Medicaid Services, attended briefly, according to officials at the American College of Emergency Physicians. ACEP was having its proposal evaluated by PTAC.

Physician organizations have been puzzled as to why federal health officials have yet to approve a physician-developed alternative payment model (APM) under the Quality Payment Program, despite several being recommended by PTAC. In fact, no physician-developed APM has even been sent to the Center for Medicare and Medicaid Innovation for further testing and refinement.

ACEP’s model, the Acute Unscheduled Care Model, “provides incentives to safely discharge Medicare beneficiaries from the ED by facilitating and rewarding postdischarge care coordination,” the organizations notes in the model description submitted to PTAC. “The model ensures that emergency physicians who make the decision to provide safe, efficient outpatient care have the necessary tools to support this transformation and are rewarded for their decision making.”

Going into the meeting, the preliminary evaluation report had the PTAC reviewers agreeing unanimously that the model met 7 of the secretary’s 10 criteria for a physician-focused APM, that the majority agreed on the 8th criterion, and a majority agreed that the model did not meet criteria on the remaining two items.

PTAC reviewers “thought that we met all 10 criteria for models that the secretary put forth for evaluating physician-focused payment models,” Jeffrey Davis, ACEP Director of Regulatory Affairs, said in an interview, adding that the attendance of Mr. Azar and Ms. Verma at the meeting was a positive development.

“I think we were especially inspired by the fact that Secretary Azar, Administrator Verma, and Adam Boehler, the new head of [Center for Medicare and Medicaid Innovation], spoke at the beginning of the PTAC meeting,” he said, adding that while no models have been formally implemented or even designated for testing, they said that ideas are being incorporated into model development going on at the CMS.

Ms. Verma went so far as to tweet that “this group of leading experts volunteer their time to improve our healthcare system, and we greatly value their input.”

“We still think [PTAC] is a great avenue to get our model into the public arena,” Mr. Davis said. “We are optimistic.”

[email protected]

Recommendations on potential physician-focused alternative payment models so far have gained little traction with officials at the Centers for Medicare & Medicaid Services, but that could be changing.

TheaDesign/Thinkstock

At a recent meeting of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), Alex Azar, secretary of the Department of Health & Human Services, and Seema Verma, administrator of the Centers for Medicare & Medicaid Services, attended briefly, according to officials at the American College of Emergency Physicians. ACEP was having its proposal evaluated by PTAC.

Physician organizations have been puzzled as to why federal health officials have yet to approve a physician-developed alternative payment model (APM) under the Quality Payment Program, despite several being recommended by PTAC. In fact, no physician-developed APM has even been sent to the Center for Medicare and Medicaid Innovation for further testing and refinement.

ACEP’s model, the Acute Unscheduled Care Model, “provides incentives to safely discharge Medicare beneficiaries from the ED by facilitating and rewarding postdischarge care coordination,” the organizations notes in the model description submitted to PTAC. “The model ensures that emergency physicians who make the decision to provide safe, efficient outpatient care have the necessary tools to support this transformation and are rewarded for their decision making.”

Going into the meeting, the preliminary evaluation report had the PTAC reviewers agreeing unanimously that the model met 7 of the secretary’s 10 criteria for a physician-focused APM, that the majority agreed on the 8th criterion, and a majority agreed that the model did not meet criteria on the remaining two items.

PTAC reviewers “thought that we met all 10 criteria for models that the secretary put forth for evaluating physician-focused payment models,” Jeffrey Davis, ACEP Director of Regulatory Affairs, said in an interview, adding that the attendance of Mr. Azar and Ms. Verma at the meeting was a positive development.

“I think we were especially inspired by the fact that Secretary Azar, Administrator Verma, and Adam Boehler, the new head of [Center for Medicare and Medicaid Innovation], spoke at the beginning of the PTAC meeting,” he said, adding that while no models have been formally implemented or even designated for testing, they said that ideas are being incorporated into model development going on at the CMS.

Ms. Verma went so far as to tweet that “this group of leading experts volunteer their time to improve our healthcare system, and we greatly value their input.”

“We still think [PTAC] is a great avenue to get our model into the public arena,” Mr. Davis said. “We are optimistic.”

[email protected]

The Centers for Medicare & Medicaid Services may be able to reduce spending through the Medicare Shared Savings Program (MSSP) without asking for health care professionals and organizations to take on penalties or so-called downside risk, according to a study published in Sept. 5 in the New England Journal of Medicine.

TheaDesign/Thinkstock

Researchers, using fee-for-service claims from 2009 through 2015 and performing difference-in-difference analyses to compare changes in Medicare spending, found that Accountable Care Organizations (ACOs) formed from physician practices were able to save money while hospital-based ACOs were not.

“Our results also suggest that shared-savings contracts that do not impose a downside risk of financial losses for spending above benchmarks – which may appeal to smaller organizations without sufficient reserves to withstand potential losses – may be effective in lowering Medicare spending,” J. Michael McWilliams, MD, PhD, of Harvard Medical School, Boston, and his colleagues wrote.

Researchers found that by 2015, groups participating in MSSP, as compared with those who did not participate, were “associated with a mean differential reduction of $302 in total Medicare spending per beneficiary in the 2012 entry of cohorts of ACOs,” without accounting for bonus payments.

“Accounting for shared-savings bonus payments, we determined that the differential spending reductions in the entry cohorts of physician-group ACOs from 2012 through 2014 constituted a net savings to Medicare of $256.4 million in 2015,” Dr. McWilliams and his colleagues wrote. “For hospital-integrated ACOs, bonus payments more than offset annual spending reductions.”

Dr. McWilliams and his colleagues noted that their findings were limited by a narrow focus on organizational structure (financial independence from hospitals), so other factors could have held to differences in savings; changes in coding practices for ACOs coming in as of 2013; lack of data on costs to ACOs or efforts to lower spending or improve quality; and the inability to assess the effects of the MSSP on many aspects of quality of care because of the nature of using claims-based measures.

“Our results probably underestimate savings to Medicare because they do not account for spillover effects of ACO efforts on nonattributed patients or effects of lower fee-for-service Medicare spending on payments to Medicare Advantage plans,” the researchers added.

The study was funded by a grant from the National Institute on Aging. Dr. McWilliams and Michael Chernew, PhD, also of Harvard Medical School, both have received consulting fees related to ACO research.

[email protected]

SOURCE: McWilliams JM et al. N Engl J Med. 2018 Sep 5. doi: 10.1056/NEJMsa1803388.

The Centers for Medicare & Medicaid Services may be able to reduce spending through the Medicare Shared Savings Program (MSSP) without asking for health care professionals and organizations to take on penalties or so-called downside risk, according to a study published in Sept. 5 in the New England Journal of Medicine.

TheaDesign/Thinkstock

Researchers, using fee-for-service claims from 2009 through 2015 and performing difference-in-difference analyses to compare changes in Medicare spending, found that Accountable Care Organizations (ACOs) formed from physician practices were able to save money while hospital-based ACOs were not.

“Our results also suggest that shared-savings contracts that do not impose a downside risk of financial losses for spending above benchmarks – which may appeal to smaller organizations without sufficient reserves to withstand potential losses – may be effective in lowering Medicare spending,” J. Michael McWilliams, MD, PhD, of Harvard Medical School, Boston, and his colleagues wrote.

Researchers found that by 2015, groups participating in MSSP, as compared with those who did not participate, were “associated with a mean differential reduction of $302 in total Medicare spending per beneficiary in the 2012 entry of cohorts of ACOs,” without accounting for bonus payments.

“Accounting for shared-savings bonus payments, we determined that the differential spending reductions in the entry cohorts of physician-group ACOs from 2012 through 2014 constituted a net savings to Medicare of $256.4 million in 2015,” Dr. McWilliams and his colleagues wrote. “For hospital-integrated ACOs, bonus payments more than offset annual spending reductions.”

Dr. McWilliams and his colleagues noted that their findings were limited by a narrow focus on organizational structure (financial independence from hospitals), so other factors could have held to differences in savings; changes in coding practices for ACOs coming in as of 2013; lack of data on costs to ACOs or efforts to lower spending or improve quality; and the inability to assess the effects of the MSSP on many aspects of quality of care because of the nature of using claims-based measures.

“Our results probably underestimate savings to Medicare because they do not account for spillover effects of ACO efforts on nonattributed patients or effects of lower fee-for-service Medicare spending on payments to Medicare Advantage plans,” the researchers added.

The study was funded by a grant from the National Institute on Aging. Dr. McWilliams and Michael Chernew, PhD, also of Harvard Medical School, both have received consulting fees related to ACO research.

[email protected]

SOURCE: McWilliams JM et al. N Engl J Med. 2018 Sep 5. doi: 10.1056/NEJMsa1803388.

The Centers for Medicare & Medicaid Services may be able to reduce spending through the Medicare Shared Savings Program (MSSP) without asking for health care professionals and organizations to take on penalties or so-called downside risk, according to a study published in Sept. 5 in the New England Journal of Medicine.

TheaDesign/Thinkstock

Researchers, using fee-for-service claims from 2009 through 2015 and performing difference-in-difference analyses to compare changes in Medicare spending, found that Accountable Care Organizations (ACOs) formed from physician practices were able to save money while hospital-based ACOs were not.

“Our results also suggest that shared-savings contracts that do not impose a downside risk of financial losses for spending above benchmarks – which may appeal to smaller organizations without sufficient reserves to withstand potential losses – may be effective in lowering Medicare spending,” J. Michael McWilliams, MD, PhD, of Harvard Medical School, Boston, and his colleagues wrote.

Researchers found that by 2015, groups participating in MSSP, as compared with those who did not participate, were “associated with a mean differential reduction of $302 in total Medicare spending per beneficiary in the 2012 entry of cohorts of ACOs,” without accounting for bonus payments.

“Accounting for shared-savings bonus payments, we determined that the differential spending reductions in the entry cohorts of physician-group ACOs from 2012 through 2014 constituted a net savings to Medicare of $256.4 million in 2015,” Dr. McWilliams and his colleagues wrote. “For hospital-integrated ACOs, bonus payments more than offset annual spending reductions.”

Dr. McWilliams and his colleagues noted that their findings were limited by a narrow focus on organizational structure (financial independence from hospitals), so other factors could have held to differences in savings; changes in coding practices for ACOs coming in as of 2013; lack of data on costs to ACOs or efforts to lower spending or improve quality; and the inability to assess the effects of the MSSP on many aspects of quality of care because of the nature of using claims-based measures.

“Our results probably underestimate savings to Medicare because they do not account for spillover effects of ACO efforts on nonattributed patients or effects of lower fee-for-service Medicare spending on payments to Medicare Advantage plans,” the researchers added.

The study was funded by a grant from the National Institute on Aging. Dr. McWilliams and Michael Chernew, PhD, also of Harvard Medical School, both have received consulting fees related to ACO research.

[email protected]

SOURCE: McWilliams JM et al. N Engl J Med. 2018 Sep 5. doi: 10.1056/NEJMsa1803388.

Some policy responses to the opioid epidemic have immediate, beneficial effects, while others lead to short-term harms that might be offset by long-term health benefits, according to researchers who have mathematically modeled the impact of 11 interventions.

Policies that expand addiction treatment or curb harmful effects of addiction such as overdose and infection were immediately beneficial in the model, with no negative effects on life years (LYs), quality-adjusted life years (QALYs), or addiction deaths, the researchers reported.

In contrast, policies that constrain prescription opioid supply resulted in some benefits, but also short-term harms because of inadequate pain control and users switching to heroin.

However, the modeling study also suggests those harms might be mitigated over the long term as new addictions are averted, according to Allison L. Pitt, a PhD candidate in the department of management science and engineering at Stanford (Calif.) University, and her coauthors.

Combining different interventions had additive benefits in the model, prompting Ms. Pitt and her coauthors to recommend a multifaceted policy approach to curb opioid abuse and reduce addiction deaths.

“No epidemic has ever been averted solely by treating single affected cases,” they wrote in the American Journal of Public Health. “Instead, portfolios of policies will likely be required, including those that prevent addiction, treat addiction, and mitigate its effects.”

In their study, Ms. Pitt and her colleagues projected the impact of 11 policies aimed at curbing opioid addiction and reducing addiction deaths. They used dynamic compartmental modeling, a technique commonly used for evaluating the spread of contagious disease.

This technique is appropriate for studying the opioid epidemic, because it allows for dynamic modeling of addiction incidence that reflects a changing number of prescription holders, the authors said in their report, which focused on projected outcomes of various interventions at 5 and 10 years.

None of the policies substantially reduced opioid-related deaths in 5-year outcomes projections, they found. Increasing availability of naloxone averted 4% of addiction deaths, the highest reduction of any intervention over that time period.

However, interventions focused on providing services for people with addictions did generally provide uniform benefits over the 5-year horizon: “Naloxone availability, needle exchange, medication-assisted treatment, and psychosocial treatment policies generate gains in LYs and QALYs and reduce deaths, without harming any group,” Ms. Pitt and her coauthors said.

Interventions that reduced opioid supply, such as excess opioid disposal and reduced prescribing for transitioning pain, increased LYs and QALYs while decreasing total addiction deaths over 5 years. However, the investigators said, those benefits were partly offset by increases in heroin-related deaths.

Drug rescheduling was associated with a 45.6% increase in heroin-related deaths over 5 years in the model, the highest percentage increase of any intervention in the published data.

Over the 10-year horizon, addiction deaths continued to decrease proportionally for naloxone availability and needle-exchange policies, authors said. By comparison, policies focused on opioid supply, such as excess opioid disposal and reduced prescribing for transitioning pain, averted substantially more deaths over 10 years than would be expected, compared with the 5-year results, investigators said.

Acute pain prescribing, which increased opioid-related deaths over 5 years in the model, was associated with a decrease in opioid-related deaths over 10 years, they added.

The report coauthors were Keith Humphreys, PhD, of Stanford’s department of psychiatry and behavioral sciences, and Margaret L. Brandeau, PhD, of the university’s department of management science and engineering.

The coauthors cited several limitations. One is that the opioid epidemic is changing in unpredictable ways. Therefore, numerous assumptions about the epidemic were made based on the opinions of clinicians and scientists.

The study was supported by a grant from the National Institute on Drug Abuse. Dr. Humphreys reported support through a Senior Career Research Scientist award from the VA Health Services Research and Development Service.

SOURCE: Pitt AL et al. Am J Public Health. 2018 Aug 23. doi: 10.2105/AJPH.2018.304590.

Some policy responses to the opioid epidemic have immediate, beneficial effects, while others lead to short-term harms that might be offset by long-term health benefits, according to researchers who have mathematically modeled the impact of 11 interventions.

Policies that expand addiction treatment or curb harmful effects of addiction such as overdose and infection were immediately beneficial in the model, with no negative effects on life years (LYs), quality-adjusted life years (QALYs), or addiction deaths, the researchers reported.

In contrast, policies that constrain prescription opioid supply resulted in some benefits, but also short-term harms because of inadequate pain control and users switching to heroin.

However, the modeling study also suggests those harms might be mitigated over the long term as new addictions are averted, according to Allison L. Pitt, a PhD candidate in the department of management science and engineering at Stanford (Calif.) University, and her coauthors.

Combining different interventions had additive benefits in the model, prompting Ms. Pitt and her coauthors to recommend a multifaceted policy approach to curb opioid abuse and reduce addiction deaths.

“No epidemic has ever been averted solely by treating single affected cases,” they wrote in the American Journal of Public Health. “Instead, portfolios of policies will likely be required, including those that prevent addiction, treat addiction, and mitigate its effects.”

In their study, Ms. Pitt and her colleagues projected the impact of 11 policies aimed at curbing opioid addiction and reducing addiction deaths. They used dynamic compartmental modeling, a technique commonly used for evaluating the spread of contagious disease.

This technique is appropriate for studying the opioid epidemic, because it allows for dynamic modeling of addiction incidence that reflects a changing number of prescription holders, the authors said in their report, which focused on projected outcomes of various interventions at 5 and 10 years.

None of the policies substantially reduced opioid-related deaths in 5-year outcomes projections, they found. Increasing availability of naloxone averted 4% of addiction deaths, the highest reduction of any intervention over that time period.

However, interventions focused on providing services for people with addictions did generally provide uniform benefits over the 5-year horizon: “Naloxone availability, needle exchange, medication-assisted treatment, and psychosocial treatment policies generate gains in LYs and QALYs and reduce deaths, without harming any group,” Ms. Pitt and her coauthors said.

Interventions that reduced opioid supply, such as excess opioid disposal and reduced prescribing for transitioning pain, increased LYs and QALYs while decreasing total addiction deaths over 5 years. However, the investigators said, those benefits were partly offset by increases in heroin-related deaths.

Drug rescheduling was associated with a 45.6% increase in heroin-related deaths over 5 years in the model, the highest percentage increase of any intervention in the published data.

Over the 10-year horizon, addiction deaths continued to decrease proportionally for naloxone availability and needle-exchange policies, authors said. By comparison, policies focused on opioid supply, such as excess opioid disposal and reduced prescribing for transitioning pain, averted substantially more deaths over 10 years than would be expected, compared with the 5-year results, investigators said.

Acute pain prescribing, which increased opioid-related deaths over 5 years in the model, was associated with a decrease in opioid-related deaths over 10 years, they added.

The report coauthors were Keith Humphreys, PhD, of Stanford’s department of psychiatry and behavioral sciences, and Margaret L. Brandeau, PhD, of the university’s department of management science and engineering.

The coauthors cited several limitations. One is that the opioid epidemic is changing in unpredictable ways. Therefore, numerous assumptions about the epidemic were made based on the opinions of clinicians and scientists.

The study was supported by a grant from the National Institute on Drug Abuse. Dr. Humphreys reported support through a Senior Career Research Scientist award from the VA Health Services Research and Development Service.

SOURCE: Pitt AL et al. Am J Public Health. 2018 Aug 23. doi: 10.2105/AJPH.2018.304590.

Some policy responses to the opioid epidemic have immediate, beneficial effects, while others lead to short-term harms that might be offset by long-term health benefits, according to researchers who have mathematically modeled the impact of 11 interventions.

Policies that expand addiction treatment or curb harmful effects of addiction such as overdose and infection were immediately beneficial in the model, with no negative effects on life years (LYs), quality-adjusted life years (QALYs), or addiction deaths, the researchers reported.

In contrast, policies that constrain prescription opioid supply resulted in some benefits, but also short-term harms because of inadequate pain control and users switching to heroin.

However, the modeling study also suggests those harms might be mitigated over the long term as new addictions are averted, according to Allison L. Pitt, a PhD candidate in the department of management science and engineering at Stanford (Calif.) University, and her coauthors.

Combining different interventions had additive benefits in the model, prompting Ms. Pitt and her coauthors to recommend a multifaceted policy approach to curb opioid abuse and reduce addiction deaths.

“No epidemic has ever been averted solely by treating single affected cases,” they wrote in the American Journal of Public Health. “Instead, portfolios of policies will likely be required, including those that prevent addiction, treat addiction, and mitigate its effects.”

In their study, Ms. Pitt and her colleagues projected the impact of 11 policies aimed at curbing opioid addiction and reducing addiction deaths. They used dynamic compartmental modeling, a technique commonly used for evaluating the spread of contagious disease.

This technique is appropriate for studying the opioid epidemic, because it allows for dynamic modeling of addiction incidence that reflects a changing number of prescription holders, the authors said in their report, which focused on projected outcomes of various interventions at 5 and 10 years.

None of the policies substantially reduced opioid-related deaths in 5-year outcomes projections, they found. Increasing availability of naloxone averted 4% of addiction deaths, the highest reduction of any intervention over that time period.

However, interventions focused on providing services for people with addictions did generally provide uniform benefits over the 5-year horizon: “Naloxone availability, needle exchange, medication-assisted treatment, and psychosocial treatment policies generate gains in LYs and QALYs and reduce deaths, without harming any group,” Ms. Pitt and her coauthors said.

Interventions that reduced opioid supply, such as excess opioid disposal and reduced prescribing for transitioning pain, increased LYs and QALYs while decreasing total addiction deaths over 5 years. However, the investigators said, those benefits were partly offset by increases in heroin-related deaths.

Drug rescheduling was associated with a 45.6% increase in heroin-related deaths over 5 years in the model, the highest percentage increase of any intervention in the published data.

Over the 10-year horizon, addiction deaths continued to decrease proportionally for naloxone availability and needle-exchange policies, authors said. By comparison, policies focused on opioid supply, such as excess opioid disposal and reduced prescribing for transitioning pain, averted substantially more deaths over 10 years than would be expected, compared with the 5-year results, investigators said.

Acute pain prescribing, which increased opioid-related deaths over 5 years in the model, was associated with a decrease in opioid-related deaths over 10 years, they added.

The report coauthors were Keith Humphreys, PhD, of Stanford’s department of psychiatry and behavioral sciences, and Margaret L. Brandeau, PhD, of the university’s department of management science and engineering.

The coauthors cited several limitations. One is that the opioid epidemic is changing in unpredictable ways. Therefore, numerous assumptions about the epidemic were made based on the opinions of clinicians and scientists.

The study was supported by a grant from the National Institute on Drug Abuse. Dr. Humphreys reported support through a Senior Career Research Scientist award from the VA Health Services Research and Development Service.

SOURCE: Pitt AL et al. Am J Public Health. 2018 Aug 23. doi: 10.2105/AJPH.2018.304590.

Accountable care organizations (ACOs) are playing it too safe, according to the Centers for Medicare & Medicaid Services, which wants to change the rules and push more ACOs into taking on more financial risk – with a little flexibility added in.

“ACOs were designed to move Medicare away from fee for service by encouraging providers to find efficiencies and innovative ways to deliver high-quality care to their patients while reducing costs, giving them the flexibility they need to focus on health outcomes over process,” CMS Administrator Seema Verma said during an Aug. 9 press conference.

That’s not what is happening now, Ms. Verma said. Under the current program, physicians and other health care professionals can participate in an ACO that takes on upside risk only – that is, to share in any of the savings it is able to generate – for up to 6 years before having to take on downside risk to return payment to the government if the ACO fails to hit spending targets.

“This environment has created a perverse incentive leading to the shocking present day reality that, after 6 years, over 82% of shared saving program ACOs are in an upside-only track, meaning that these ACOs have no incentive at all to reduce health care cost while improving outcomes as they were intended,” she said. “The program has not lived up to the accountability part of their name.”

In the aggregate, ACOs that only take on upside risk generally are spending more money and not generating the savings that ACOs in a two-sided risk arrangement are, she added.

To get more health care professionals into two-sided risk arrangements, the CMS released a proposed rule Aug. 9 that caps ACO participation in an upside risk–only arrangement for 2 years before having to migrate to a two-sided risk arrangement. To sweeten the pot, the CMS proposes to allow more flexibility for innovation and encouraging patients to maintain their health.

“On top of [antikickback law] waivers they already receive, we are proposing to allow ACOs that are taking risk to give incentive payments in order to reward patients for taking steps to achieve good health, such as gift cards for patients who receive necessary primary and preventive care,” she said, adding that ACOs who take on downside risk also will be eligible to receive payments for providing telehealth services.

ACOs also will need to adopt the 2015 edition of certified EHR technology and the CMS also will be looking to streamline quality measures, according to the proposal.

The CMS is extending current ACO contracts for 6 months, with the new rules, if finalized, going into effect in the middle of 2019.

The proposal also simplifies the ACO program by offering two tracks, as detailed in a blog post penned by Administrator Verma that appeared Aug. 9 in Health Affairs.

The Basic track “would feature a glide path for taking risk,” she wrote. “It would begin with up to 2 years of upside-only risk and then gradually transition in years 3, 4, and 5 to increasing levels of performance risk, concluding in year 5 at a level of risk that meets the standard to qualify as an advanced alternative payment model [APM]” under the Quality Payment Program. Those entering the enhanced track, taking on two-sided risk immediately, would need to meet the standard of an APM immediately.

The proposal also calls for more transparency and would require providers to alert Medicare beneficiaries that services are being provided in the context of an ACO and to explain what that means for their care.

Spending benchmarks would continue to be calculated using both regional and national spending trends. Program integrity also will be enhanced “by holding ACOs in two-sided models accountable for losses even if they exit midway through a performance year, and by authorizing termination of ACOs with multiple years of poor financial performance,” Ms. Verma wrote.

The Pathways to Success proposed rule was slated to be published in the Federal Register on Aug. 17. Comments are being accepted at regulations.gov until Oct. 16.

[email protected]

Accountable care organizations (ACOs) are playing it too safe, according to the Centers for Medicare & Medicaid Services, which wants to change the rules and push more ACOs into taking on more financial risk – with a little flexibility added in.

“ACOs were designed to move Medicare away from fee for service by encouraging providers to find efficiencies and innovative ways to deliver high-quality care to their patients while reducing costs, giving them the flexibility they need to focus on health outcomes over process,” CMS Administrator Seema Verma said during an Aug. 9 press conference.

That’s not what is happening now, Ms. Verma said. Under the current program, physicians and other health care professionals can participate in an ACO that takes on upside risk only – that is, to share in any of the savings it is able to generate – for up to 6 years before having to take on downside risk to return payment to the government if the ACO fails to hit spending targets.

“This environment has created a perverse incentive leading to the shocking present day reality that, after 6 years, over 82% of shared saving program ACOs are in an upside-only track, meaning that these ACOs have no incentive at all to reduce health care cost while improving outcomes as they were intended,” she said. “The program has not lived up to the accountability part of their name.”

In the aggregate, ACOs that only take on upside risk generally are spending more money and not generating the savings that ACOs in a two-sided risk arrangement are, she added.

To get more health care professionals into two-sided risk arrangements, the CMS released a proposed rule Aug. 9 that caps ACO participation in an upside risk–only arrangement for 2 years before having to migrate to a two-sided risk arrangement. To sweeten the pot, the CMS proposes to allow more flexibility for innovation and encouraging patients to maintain their health.

“On top of [antikickback law] waivers they already receive, we are proposing to allow ACOs that are taking risk to give incentive payments in order to reward patients for taking steps to achieve good health, such as gift cards for patients who receive necessary primary and preventive care,” she said, adding that ACOs who take on downside risk also will be eligible to receive payments for providing telehealth services.

ACOs also will need to adopt the 2015 edition of certified EHR technology and the CMS also will be looking to streamline quality measures, according to the proposal.

The CMS is extending current ACO contracts for 6 months, with the new rules, if finalized, going into effect in the middle of 2019.

The proposal also simplifies the ACO program by offering two tracks, as detailed in a blog post penned by Administrator Verma that appeared Aug. 9 in Health Affairs.

The Basic track “would feature a glide path for taking risk,” she wrote. “It would begin with up to 2 years of upside-only risk and then gradually transition in years 3, 4, and 5 to increasing levels of performance risk, concluding in year 5 at a level of risk that meets the standard to qualify as an advanced alternative payment model [APM]” under the Quality Payment Program. Those entering the enhanced track, taking on two-sided risk immediately, would need to meet the standard of an APM immediately.

The proposal also calls for more transparency and would require providers to alert Medicare beneficiaries that services are being provided in the context of an ACO and to explain what that means for their care.

Spending benchmarks would continue to be calculated using both regional and national spending trends. Program integrity also will be enhanced “by holding ACOs in two-sided models accountable for losses even if they exit midway through a performance year, and by authorizing termination of ACOs with multiple years of poor financial performance,” Ms. Verma wrote.

The Pathways to Success proposed rule was slated to be published in the Federal Register on Aug. 17. Comments are being accepted at regulations.gov until Oct. 16.

[email protected]

Accountable care organizations (ACOs) are playing it too safe, according to the Centers for Medicare & Medicaid Services, which wants to change the rules and push more ACOs into taking on more financial risk – with a little flexibility added in.

“ACOs were designed to move Medicare away from fee for service by encouraging providers to find efficiencies and innovative ways to deliver high-quality care to their patients while reducing costs, giving them the flexibility they need to focus on health outcomes over process,” CMS Administrator Seema Verma said during an Aug. 9 press conference.

That’s not what is happening now, Ms. Verma said. Under the current program, physicians and other health care professionals can participate in an ACO that takes on upside risk only – that is, to share in any of the savings it is able to generate – for up to 6 years before having to take on downside risk to return payment to the government if the ACO fails to hit spending targets.

“This environment has created a perverse incentive leading to the shocking present day reality that, after 6 years, over 82% of shared saving program ACOs are in an upside-only track, meaning that these ACOs have no incentive at all to reduce health care cost while improving outcomes as they were intended,” she said. “The program has not lived up to the accountability part of their name.”

In the aggregate, ACOs that only take on upside risk generally are spending more money and not generating the savings that ACOs in a two-sided risk arrangement are, she added.

To get more health care professionals into two-sided risk arrangements, the CMS released a proposed rule Aug. 9 that caps ACO participation in an upside risk–only arrangement for 2 years before having to migrate to a two-sided risk arrangement. To sweeten the pot, the CMS proposes to allow more flexibility for innovation and encouraging patients to maintain their health.

“On top of [antikickback law] waivers they already receive, we are proposing to allow ACOs that are taking risk to give incentive payments in order to reward patients for taking steps to achieve good health, such as gift cards for patients who receive necessary primary and preventive care,” she said, adding that ACOs who take on downside risk also will be eligible to receive payments for providing telehealth services.

ACOs also will need to adopt the 2015 edition of certified EHR technology and the CMS also will be looking to streamline quality measures, according to the proposal.

The CMS is extending current ACO contracts for 6 months, with the new rules, if finalized, going into effect in the middle of 2019.

The proposal also simplifies the ACO program by offering two tracks, as detailed in a blog post penned by Administrator Verma that appeared Aug. 9 in Health Affairs.

The Basic track “would feature a glide path for taking risk,” she wrote. “It would begin with up to 2 years of upside-only risk and then gradually transition in years 3, 4, and 5 to increasing levels of performance risk, concluding in year 5 at a level of risk that meets the standard to qualify as an advanced alternative payment model [APM]” under the Quality Payment Program. Those entering the enhanced track, taking on two-sided risk immediately, would need to meet the standard of an APM immediately.

The proposal also calls for more transparency and would require providers to alert Medicare beneficiaries that services are being provided in the context of an ACO and to explain what that means for their care.

Spending benchmarks would continue to be calculated using both regional and national spending trends. Program integrity also will be enhanced “by holding ACOs in two-sided models accountable for losses even if they exit midway through a performance year, and by authorizing termination of ACOs with multiple years of poor financial performance,” Ms. Verma wrote.

The Pathways to Success proposed rule was slated to be published in the Federal Register on Aug. 17. Comments are being accepted at regulations.gov until Oct. 16.

[email protected]

In the wild world of health care rankings, a year can make a big difference … or not.

After finishing eighth last year, Vermont’s health care system moved up to first in personal finance website WalletHub’s rankings for 2018 and Hawaii, which took the top spot in 2017, dropped to fifth. Iowa fell from second to ninth over the course of the last year while Connecticut and South Dakota moved out of the top 10 to make way for Colorado and Maryland, according to WalletHub.

There was less movement at the other end of the rankings, however, with no change at all in the bottom five: Louisiana finished 51st again (the rankings include the District of Columbia), preceded by fellow repeaters Mississippi (50), Alaska (49), Arkansas (48), and North Carolina (47). Texas and Nevada did manage to move on up out of the bottom 11 – to 38th and 40th, respectively – at the expense of Oklahoma and Tennessee, WalletHub reported.

For 2018, the company compared the states and D.C. “across 40 measures of cost, accessibility and outcome,” which is five more measures than last year and a possible explanation for the changes at the top. The cost dimension’s five metrics included cost of medical visits and share of high out-of-pocket medical spending. The accessibility dimension consisted of 21 metrics, including average emergency department wait time and share of insured children. The outcomes dimension included 14 metrics, among them maternal mortality rate and share of adults with type 2 diabetes.

Vermont did well in both the outcomes (first) and cost (third) dimensions but only middle of the pack (23rd) in access. The District of Columbia was ranked first in cost and Maine was the leader in access. The lowest-ranked states in each category were Alaska (cost), Texas (access), and Mississippi (outcomes), according to the WalletHub analysis, which was based on data from such sources as the Centers for Disease Control and Prevention, the Health Resources & Services Administration, and the United Health Foundation.

[email protected]

In the wild world of health care rankings, a year can make a big difference … or not.

After finishing eighth last year, Vermont’s health care system moved up to first in personal finance website WalletHub’s rankings for 2018 and Hawaii, which took the top spot in 2017, dropped to fifth. Iowa fell from second to ninth over the course of the last year while Connecticut and South Dakota moved out of the top 10 to make way for Colorado and Maryland, according to WalletHub.

There was less movement at the other end of the rankings, however, with no change at all in the bottom five: Louisiana finished 51st again (the rankings include the District of Columbia), preceded by fellow repeaters Mississippi (50), Alaska (49), Arkansas (48), and North Carolina (47). Texas and Nevada did manage to move on up out of the bottom 11 – to 38th and 40th, respectively – at the expense of Oklahoma and Tennessee, WalletHub reported.

For 2018, the company compared the states and D.C. “across 40 measures of cost, accessibility and outcome,” which is five more measures than last year and a possible explanation for the changes at the top. The cost dimension’s five metrics included cost of medical visits and share of high out-of-pocket medical spending. The accessibility dimension consisted of 21 metrics, including average emergency department wait time and share of insured children. The outcomes dimension included 14 metrics, among them maternal mortality rate and share of adults with type 2 diabetes.

Vermont did well in both the outcomes (first) and cost (third) dimensions but only middle of the pack (23rd) in access. The District of Columbia was ranked first in cost and Maine was the leader in access. The lowest-ranked states in each category were Alaska (cost), Texas (access), and Mississippi (outcomes), according to the WalletHub analysis, which was based on data from such sources as the Centers for Disease Control and Prevention, the Health Resources & Services Administration, and the United Health Foundation.

[email protected]

In the wild world of health care rankings, a year can make a big difference … or not.

After finishing eighth last year, Vermont’s health care system moved up to first in personal finance website WalletHub’s rankings for 2018 and Hawaii, which took the top spot in 2017, dropped to fifth. Iowa fell from second to ninth over the course of the last year while Connecticut and South Dakota moved out of the top 10 to make way for Colorado and Maryland, according to WalletHub.

There was less movement at the other end of the rankings, however, with no change at all in the bottom five: Louisiana finished 51st again (the rankings include the District of Columbia), preceded by fellow repeaters Mississippi (50), Alaska (49), Arkansas (48), and North Carolina (47). Texas and Nevada did manage to move on up out of the bottom 11 – to 38th and 40th, respectively – at the expense of Oklahoma and Tennessee, WalletHub reported.

For 2018, the company compared the states and D.C. “across 40 measures of cost, accessibility and outcome,” which is five more measures than last year and a possible explanation for the changes at the top. The cost dimension’s five metrics included cost of medical visits and share of high out-of-pocket medical spending. The accessibility dimension consisted of 21 metrics, including average emergency department wait time and share of insured children. The outcomes dimension included 14 metrics, among them maternal mortality rate and share of adults with type 2 diabetes.

Vermont did well in both the outcomes (first) and cost (third) dimensions but only middle of the pack (23rd) in access. The District of Columbia was ranked first in cost and Maine was the leader in access. The lowest-ranked states in each category were Alaska (cost), Texas (access), and Mississippi (outcomes), according to the WalletHub analysis, which was based on data from such sources as the Centers for Disease Control and Prevention, the Health Resources & Services Administration, and the United Health Foundation.

[email protected]

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Editor’s note: The “Legacies of Hospital Medicine” is a recurring opinion column submitted by some of the best and brightest hospitalists in the field, who have helped shape our specialty into what it is today. It is a series of articles that reflect on Hospital Medicine and its evolution over time, from a variety of unique and innovative perspectives.
 

Medical professional societies have many goals and serve numerous functions. Some of these include education and training, professional development, and shaping the perception of their specialty both in the medical world and the public arena. Advocacy and governmental affairs are also on that list. SHM is no exception to that rule, although we have taken what is clearly an unorthodox approach to those efforts and our strategy has resulted in an unusual amount of success for a society of our size and age.

As my contribution to the “Legacies” series, I am calling upon my 20-year history of participation in SHM’s advocacy and policy efforts to describe that approach, recount some of the history of our efforts, and to talk a bit about our current activities, goals, and strategies.

In 1999 the leadership of SHM decided to create the Public Policy Committee and to provide resources for what was, at the time, a single dedicated staff position to support the work of the committee. As nascent as our efforts were, the strategy for entering into the Washington fray was clear. We decided our priorities were first and foremost to educate our “targets” on exactly what a hospitalist was and on the increasing role hospitalists were playing in the American health care system.

The target audience was (and has remained) Congress, the Centers for Medicare and Medicaid Services, and the Medicare Payment Advisory Committee, which is the advisory board tasked to recommend to Congress how Medicare should spend its resources. The goal of this education was to establish our credibility and to advance the notion that we were the experts on care design for acutely ill patients in the inpatient setting. To this end, we decided that, when we met with folks on the Hill, we would ask for nothing for ourselves or our members, an approach that was virtually unheard of in the halls of Congress.

When responding to questions as to why we were not bringing “asks” to our Hill meetings, we would simply comment that we were only offering our services. And whenever they decided to try to make the health care system better and expertise was required regarding redesign of care in the hospital, they should think about us. Our stated goal: improve the delivery system and provide better and more cost-effective care for our patients.

We also exercised what I will call “issue discipline.” With very limited resources it was critical that we limit our issues to ones on which we could have significant impact, and had enough expertise to shape an effective argument. In addition, as we were going to be operating within a highly partisan system and representing members with varying political views, it was highly important that we did not approach issues in a way that resulted in our appearing politically motivated.

That approach took a lot of time and patience. But as a small and relatively under-resourced organization, we saw it as the only way that we could eventually have our message heard. So for many years the small contingent of SHM staff and the members of the Public Policy Committee (PPC) worked quietly to have our specialty and society recognized by policy makers in Washington and Baltimore (where CMS resides). But in the years just prior to and since the passage of the Affordable Care Act, when serious redesign of the American health care system began, our patience started to pay dividends and policy makers actually reached out for our input on issues related to the care of patients admitted to acute care hospitals. In addition, our advocacy efforts started to gain more traction.

Today, our specialty and society are well known by the key health care policymakers at CMS, MedPAC, and the Center for Medicare and Medicaid Innovation (CMMI), the latter of which was created by the ACA and whose role is to test the new alternative payment models (like accountable care organizations and bundled payments) to find out if they actually lead to better outcomes and lower costs. In the halls of Congress, especially with the health care staff for the committees of jurisdiction for federal health care legislation, our society is seen as an “honest broker” and as an organization committed not just to the issues that impact our members, but one that has the improvement of the entire health care system at the top of its priority list. We have been told that this perception gives us a voice that is much more influential than would be expected for a society of our age, size, and resources.

Along the way, the PPC has grown to a committee of 20 select members led by committee chair Joshua Lenchus, DO, RPh, SFHM. The committee is known to be among the most difficult committees to get on, and members commit to hours of work monthly to support our efforts. Our government relations staff in Philadelphia is still small at just three, but they are extremely bright and productive. Director Josh Boswell serves as their extremely capable leader. Josh Lapps and Ellen Boyer round out the incredibly strong team. Recently, my role evolved from being the long-term chairman of the PPC to one of volunteer staff, as the senior advisor for government relations. In this role I hope to support our full time staff, especially in our Washington-facing efforts.

The SHM staff has brought several systemic improvements to our advocacy work, including execution of several highly successful “Hill Days” and, more recently, the establishment of our “Grassroots Network” that allows a wider swath of our membership to get involved in the field. The Hill Days occur during years when the SHM Annual Conference is in Washington, and one of the days includes busing hundreds of hospitalists to Capitol Hill for meetings with their representatives to discuss our advocacy issues. Our next Hill Day will be at the 2019 annual conference, and we will be signing up volunteer members for this unique experience.

The success of our advocacy can be seen in several high-level “wins” over the last few years. Some of the more notable include:

• Successful application to CMS for a specialty code for Hospital Medicine (the C6 designation), so that performance data for hospitalists will be fairly compared with other hospitalists and not with our outpatient colleagues’ performance.
• Successful support of risk adjustment of readmission rates for safety net hospitals.
• Creation of a hardship exemption of Meaningful Use penalties for hospitalists, an initiative that saved our membership approximately $37 million of unfair penalties per year; this ensured a permanent exemption from these penalties within the Medicare Access and CHIP Reauthorization Act.
• Implementation of Advanced Care Planning CPT codes to encourage appropriate use of “end of life” discussions.
• Establishment of a Hospitalist Measure set with CMS.
• Repeal of the Independent Advisory Board earlier this year.
• Creation of the “Facility Based Option” to replace Merit-Based Incentive Payment System reporting for hospital-based physicians including hospitalists. This voluntary method to replace MIPS reporting was first suggested to CMS by SHM, was developed in partnership with CMS, and will be available in 2019.

SHM continues to take the lead on issues that impact the U.S. health care system and our patients. For several years we have been explaining to CMS and Congress the complete dysfunction of observation status, and its negative impact on elderly patients and hospitals. We have taken advantage of the expertise of several members of the PPC, including research currently being done by member Ann Sheehy, MD, SFHM, to publish two iterations of a white paper on the subject, which was widely read by Hill staff and resulted in Dr. Sheehy testifying on the subject to Congress.

More recently, SHM released a consensus statement on the use of opioids in the inpatient setting, along with a policy statement on opioid abuse, both of which have been widely lauded after being distributed to key committees of both chambers of Congress. Our recommendations will undoubtedly be addressed in an opioid bill which, at the time of this writing, is moving to a vote on the Hill.

As the U.S. health care system undergoes a necessary transformation to one in which value creation is tantamount, hospitalists – by the nature of our work – are in a propitious position to guide the development of better federal policy. We still must be judicious in the use of our limited resources and circumspect in our selection of issues. And we must jealously guard the reputation we have cultivated as a medical society that is looking out for the entire health care system and its patients, while we also support our members and their work.

We want to continue to be an organization that, rather than resisting change, is focused on driving positive change through better ideas and intelligent advocacy.
 

Dr. Greeno is senior advisor for government affairs and past president of the Society of Hospital Medicine.

Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.

Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”

Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.

The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.

“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”

Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.

SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.

Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.

Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”

Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.

The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.

“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”

Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.

SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.

Among patients hospitalized with gastrointestinal and liver diseases, a clearly identifiable subset uses significantly more health care resources, which incurs significantly greater costs, according to the results of a national database analysis published in the August issue of Clinical Gastroenterology and Hepatology.

Compared with otherwise similar inpatients, these “high-need, high-cost” individuals are significantly more likely to be enrolled in Medicare or Medicaid, to have lower income, to initially be admitted to a large, rural hospital, to have multiple comorbidities, to be obese, or to be hospitalized for infection, said Nghia Nguyen, MD, and his associates. “[A] small fraction of high-need, high-cost patients contribute disproportionately to hospitalization costs,” they wrote. “Population health management directed toward these patients would facilitate high-value care.”

Gastrointestinal and liver diseases incur more than $100 billion in health care expenses annually in the United States, of which more than 60% is related to inpatient care, the researchers noted. However, few studies have comprehensively evaluated the annual burden and costs of hospitalization in patients with chronic gastrointestinal and liver diseases. Therefore, using the Nationwide Readmissions Database, the investigators studied patients with inflammatory bowel disease (IBD), chronic liver disease, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases who were hospitalized at least once during the first 6 months of 2013. All patients were diagnosed with IBD, chronic liver diseases, functional gastrointestinal disorders, gastrointestinal hemorrhage, or pancreatic diseases and followed for at least 6 months. The researchers stratified hospital days and costs and characterized the subset of patients who fell into the highest decile of days spent in the hospital per month.

The most common reason for hospitalization was chronic liver disease (nearly 377,000 patients), followed by functional gastrointestinal disorders (more than 351,000 patients), gastrointestinal hemorrhage (nearly 191,000 patients), pancreatic diseases (more than 98,000 patients), and IBD (more than 47,000 patients). Patients spent a median of 6-7 days in the hospital per year, with an interquartile range of 3-14 days. Compared with patients in the lowest decile for annual hospital stay (median, 0.13-0.14 days per month), patients in the highest decile spent a median of 3.7-5.1 days in the hospital per month. In this high-cost, high-need subset of patients, the costs of each hospitalization ranged from $7,438 per month to $11,425 per month, and they were typically hospitalized once every 2 months.

“Gastrointestinal diseases, infections, and cardiopulmonary causes were leading reasons for hospitalization of these patients,” the researchers wrote. “At a patient level, modifiable risk factors may include tackling the obesity epidemic and mental health issues and minimizing risk of iatrogenic or health care–associated infections, whereas at a health system level, interventions may include better access to care and connectivity between rural and specialty hospitals.”

Funders included the American College of Gastroenterology, the Crohn’s and Colitis Foundation, and the National Institutes of Health. Senior author Siddharth Singh disclosed unrelated grant funding from Pifzer and AbbVie. The other investigators reported having no conflicts of interest.

SOURCE: Nguyen NH et al. Clin Gastroenterol Hepatol. 2018 Feb 20. doi: 10.1016/j.cgh.2018.02.015.

Certain procedures conducted in the hospital outpatient setting could see a reimbursement cut to levels paid for under the physician fee schedule if a proposal introduced by the Centers for Medicare & Medicaid Services is finalized.

In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.

“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.

According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.

“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.

The American Hospital Association already is pushing back on this proposal.

“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”

However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.

“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.

The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”

“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.

The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.

In addition, the OPPS is seeking feedback on a number of topics.

One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.

[email protected]

Certain procedures conducted in the hospital outpatient setting could see a reimbursement cut to levels paid for under the physician fee schedule if a proposal introduced by the Centers for Medicare & Medicaid Services is finalized.

In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.

“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.

According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.

“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.

The American Hospital Association already is pushing back on this proposal.

“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”

However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.

“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.

The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”

“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.

The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.

In addition, the OPPS is seeking feedback on a number of topics.

One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.

[email protected]

Certain procedures conducted in the hospital outpatient setting could see a reimbursement cut to levels paid for under the physician fee schedule if a proposal introduced by the Centers for Medicare & Medicaid Services is finalized.

In the proposed update to the Outpatient Prospective Payment System (OPPS) for 2019, released July 27 and scheduled to be published July 31 in the Federal Register, the CMS is proposing to apply a physician fee schedule–equivalent for the clinic visit service when provided at an off-campus, provider-based department that is paid under the OPPS.

“The clinic visit is the most common service billed under the OPPS and is often furnished in the physician office setting,” the CMS said in a fact sheet detailing its proposal.

According to the CMS, the average current clinical visit paid by the CMS is $116 with $23 being the average copay by the patient. If the proposal is finalized, the payment would drop to about $46 with an average patient copay of $9.

“This is intended to address concerns about recent consolidations in the market that reduce competition,” CMS Administrator Seema Verma said during a July 25 press conference.

The American Hospital Association already is pushing back on this proposal.

“With today’s proposed rule, CMS has once again showed a lack of understanding about the reality in which hospitals and health systems operate daily to serve the needs of their communities,” AHA Executive Vice President Tom Nickels said in a statement. “In 2015, Congress clearly intended to provide current off-campus hospital clinics with the existing outpatient payment rate in recognition of the critical role they play in their communities. But CMS’s proposal runs counter to this and will instead impede access to care for the most vulnerable patients.”

However, Farzad Mostashari, MD, founder of the health care technology company Aledade and National Coordinator for Health IT under President Obama, suggested that this could actually be a good thing for hospitals.

“The truth is that this proposal could help hospitals be more competitive in value-based contracts/alternative-payment models, and they should embrace the changes,” he said in a tweet.

The OPPS update also includes proposals to expand the list of covered surgical procedures that can be performed in an ambulatory surgical center, a move that Ms. Verma said would “provide patients with more choices and options for lower-priced care.”

“For CY 2019, CMS is proposing to allow certain CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT surgical code range to be included on the [covered procedure list] and is proposing to add certain cardiovascular codes to the ASC [covered procedure list] as a result,” the CMS fact sheet notes.

The CMS also will review all procedures added to the covered procedure list in the past 3 years to determine whether such procedures should continue to be covered.

In addition, the OPPS is seeking feedback on a number of topics.

One is related to price transparency. The agency is asking “whether providers and suppliers can and should be required to inform patients about charges and payment information for healthcare services and out-of-pocket costs, what data elements the public would find most useful, and what other charges are needed to empower patients,” according to the fact sheet.

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Payment for more telemedicine services could be in store for physicians and other health providers if new proposals in the latest fee schedule from the Centers for Medicare & Medicaid Services are finalized.

Under the proposed physician fee schedule, announced July 12, the CMS would expand services that qualify for telemedicine payments and add reimbursement for virtual check-ins by phone or other technologies, such as Skype. Telemedicine clinicians would also be paid for time spent reviewing patient photos sent by text or e-mail under the suggested changes.

Such telehealth services would aid patients who have transportation difficulties by creating more opportunities for them to access personalized care, said CMS Administrator Seema Verma.

“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Ms. Verma said in a statement.

Under the proposal, physicians could bill separately for brief, non–face-to-face patient check-ins with patients via communication technology beginning January 2019. In addition, the proposed rule carves out payments for the remote professional evaluation of patient-transmitted information conducted via prerecorded “store and forward” video or image technology. Doctors could use both services to determine whether an office visit or other service is warranted, according to the proposed rule.

The services would have limitations on when they could be separately billed. In cases where the brief communication technology–based service originated from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered “bundled” into that previous E/M service and could not be billed separately. Similarly, a photo evaluation could not be separately billed if it stemmed from a related E/M service provided within the previous 7 days by the same physician, or if the evaluation results in an in-person E/M office visit with the same doctor.

Under the proposal, health providers could perform the newly covered telehealth services only with established patients, but the CMS is seeking comments as to whether in certain cases, such as dermatological or ophthalmological instances, it might be appropriate for a new patient to receive the services. Agency officials also want to know what types of communication technology are used by physicians in furnishing check-in services, including whether audio-only telephone interactions are sufficient, compared with interactions that are enhanced with video. The CMS is asking physicians whether it would be clinically appropriate to apply a frequency limitation on the use of the proposed telehealth services by the same physician.

Latoya Thomas, director of the American Telemedicine Association’s State Policy Resource Center, said the proposal is exciting because it acknowledges the pervasive growth, accessibility, and acceptance of technology advances.

“In expanding reimbursement to providers for more modality-neutral and site-neutral virtual care, such as store-and-forward and remote patient monitoring, [the rules] address longstanding barriers to broader dissemination of telehealth,” Ms. Thomas said in an interview. “By making available ‘virtual check ins’ to every Medicare beneficiary, it can improve patient engagement and reduce unnecessary trips back to their provider’s office.”

James P. Marcin, MD, a telemedicine physician and director of the Center for Health and Technology at UC Davis Children’s Hospital in Sacramento, Calif., said he was pleased with the proposed telehealth changes, but he noted that more work remains to address further telemedicine challenges.

Payment for more telemedicine services could be in store for physicians and other health providers if new proposals in the latest fee schedule from the Centers for Medicare & Medicaid Services are finalized.

Under the proposed physician fee schedule, announced July 12, the CMS would expand services that qualify for telemedicine payments and add reimbursement for virtual check-ins by phone or other technologies, such as Skype. Telemedicine clinicians would also be paid for time spent reviewing patient photos sent by text or e-mail under the suggested changes.

Such telehealth services would aid patients who have transportation difficulties by creating more opportunities for them to access personalized care, said CMS Administrator Seema Verma.

“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Ms. Verma said in a statement.

Under the proposal, physicians could bill separately for brief, non–face-to-face patient check-ins with patients via communication technology beginning January 2019. In addition, the proposed rule carves out payments for the remote professional evaluation of patient-transmitted information conducted via prerecorded “store and forward” video or image technology. Doctors could use both services to determine whether an office visit or other service is warranted, according to the proposed rule.

The services would have limitations on when they could be separately billed. In cases where the brief communication technology–based service originated from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered “bundled” into that previous E/M service and could not be billed separately. Similarly, a photo evaluation could not be separately billed if it stemmed from a related E/M service provided within the previous 7 days by the same physician, or if the evaluation results in an in-person E/M office visit with the same doctor.

Under the proposal, health providers could perform the newly covered telehealth services only with established patients, but the CMS is seeking comments as to whether in certain cases, such as dermatological or ophthalmological instances, it might be appropriate for a new patient to receive the services. Agency officials also want to know what types of communication technology are used by physicians in furnishing check-in services, including whether audio-only telephone interactions are sufficient, compared with interactions that are enhanced with video. The CMS is asking physicians whether it would be clinically appropriate to apply a frequency limitation on the use of the proposed telehealth services by the same physician.

Latoya Thomas, director of the American Telemedicine Association’s State Policy Resource Center, said the proposal is exciting because it acknowledges the pervasive growth, accessibility, and acceptance of technology advances.

“In expanding reimbursement to providers for more modality-neutral and site-neutral virtual care, such as store-and-forward and remote patient monitoring, [the rules] address longstanding barriers to broader dissemination of telehealth,” Ms. Thomas said in an interview. “By making available ‘virtual check ins’ to every Medicare beneficiary, it can improve patient engagement and reduce unnecessary trips back to their provider’s office.”

James P. Marcin, MD, a telemedicine physician and director of the Center for Health and Technology at UC Davis Children’s Hospital in Sacramento, Calif., said he was pleased with the proposed telehealth changes, but he noted that more work remains to address further telemedicine challenges.

Payment for more telemedicine services could be in store for physicians and other health providers if new proposals in the latest fee schedule from the Centers for Medicare & Medicaid Services are finalized.

Under the proposed physician fee schedule, announced July 12, the CMS would expand services that qualify for telemedicine payments and add reimbursement for virtual check-ins by phone or other technologies, such as Skype. Telemedicine clinicians would also be paid for time spent reviewing patient photos sent by text or e-mail under the suggested changes.

Such telehealth services would aid patients who have transportation difficulties by creating more opportunities for them to access personalized care, said CMS Administrator Seema Verma.

“CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner,” Ms. Verma said in a statement.

Under the proposal, physicians could bill separately for brief, non–face-to-face patient check-ins with patients via communication technology beginning January 2019. In addition, the proposed rule carves out payments for the remote professional evaluation of patient-transmitted information conducted via prerecorded “store and forward” video or image technology. Doctors could use both services to determine whether an office visit or other service is warranted, according to the proposed rule.

The services would have limitations on when they could be separately billed. In cases where the brief communication technology–based service originated from a related evaluation and management (E/M) service provided within the previous 7 days by the same physician or other qualified health care professional, the service would be considered “bundled” into that previous E/M service and could not be billed separately. Similarly, a photo evaluation could not be separately billed if it stemmed from a related E/M service provided within the previous 7 days by the same physician, or if the evaluation results in an in-person E/M office visit with the same doctor.

Under the proposal, health providers could perform the newly covered telehealth services only with established patients, but the CMS is seeking comments as to whether in certain cases, such as dermatological or ophthalmological instances, it might be appropriate for a new patient to receive the services. Agency officials also want to know what types of communication technology are used by physicians in furnishing check-in services, including whether audio-only telephone interactions are sufficient, compared with interactions that are enhanced with video. The CMS is asking physicians whether it would be clinically appropriate to apply a frequency limitation on the use of the proposed telehealth services by the same physician.

Latoya Thomas, director of the American Telemedicine Association’s State Policy Resource Center, said the proposal is exciting because it acknowledges the pervasive growth, accessibility, and acceptance of technology advances.

“In expanding reimbursement to providers for more modality-neutral and site-neutral virtual care, such as store-and-forward and remote patient monitoring, [the rules] address longstanding barriers to broader dissemination of telehealth,” Ms. Thomas said in an interview. “By making available ‘virtual check ins’ to every Medicare beneficiary, it can improve patient engagement and reduce unnecessary trips back to their provider’s office.”

James P. Marcin, MD, a telemedicine physician and director of the Center for Health and Technology at UC Davis Children’s Hospital in Sacramento, Calif., said he was pleased with the proposed telehealth changes, but he noted that more work remains to address further telemedicine challenges.