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September 2016

CMS Announces MACRA Start Date

In a blog post, Acting Administrator of CMS Andy Slavitt announced that MACRA would be implemented starting January 1, 2017. The blog post is below. The ACOS will be working on programing and other support for our members as the implementation date approaches. As the baby boom generation ages, 10,000 people enter the Medicare program each day. Facing that demand, it is essential that Medicare continues to support physicians in delivering high-quality patient care. This includes increasing its focus on patient outcomes and reducing the obstacles that make it harder for physicians to practice good care. The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) offers the opportunity to advance these goals and put Medicare on surer footing. Among other policies, it repeals the Sustainable Growth Rate formula and its annual payment cliffs, streamlines the existing patchwork of Medicare reporting programs, and provides opportunities for physicians and other clinicians to earn more by focusing on quality patient care. We are referring to these provisions of MACRA collectively as the Quality Payment Program. We received feedback on our April proposal for implementing the Quality Payment Program, both in writing and as we talked to thousands of physicians and other clinicians across the country. Universally, the clinician community wants a system that begins and ends with what’s right for the patient. We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians. We will address these areas and the many other comments we received when we release the final rule by November 1, 2016. But, with the Quality Payment Program set to begin on January 1, 2017, we wanted to share our plans for the timing of reporting for the first year of the program. In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule.

First Option: Test the Quality Payment Program

With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year

You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

Third Option: Participate for the full calendar year

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We’ve seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019. However you choose to participate in 2017, we will have resources available to assist you and walk you through what needs to be done. And however you choose to participate, your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients. We appreciate the sincere and constructive participation in the feedback process to date and look forward to advancing step-by-step in that same spirit. We look forward to releasing the final details about the program this fall. Most importantly, we look forward to further engagement with physicians and other clinicians toward our shared goal of the highest quality of care and best outcomes for patients. – The CMS Blog, Plans for the Quality Payment Program

Preparing Health Policy Options

Congress will reconvene next week following a seven-week summer recess—and there is much work to be done. Though scheduled to be in session for four weeks before recessing again until after the election, there is speculation that even this abbreviated schedule could be cut short. Before Oct. 1, Congress must pass several bills to fund federal agencies or, more likely, enact a temporary continuing resolution to extend government funding until after the election. Among the top appropriations-related priorities for medicine is the need to provide funds to address the opioid crisis and the Zika virus outbreak. While Congress has been quick to publicize passage of the Comprehensive Addiction and Recovery Act earlier in the summer, none of the newly authorized programs in the bill will receive funding until separate appropriations legislation is enacted. Congress must also return to consideration of legislation to provide support for public health efforts to address the Zika threat, including support for prevention, mosquito control and vaccine research and development. In addition to appropriations work, Congress is also likely to face renewed efforts to force action on legislation to address gun violence, such as closing loopholes in the current background check system. Additionally, while the House of Representatives acted to make important reforms to the mental health system, legislation remains pending in the Senate.

Fight Over Kentucky Medicaid Overhaul

Kentucky Gov. Matt Bevin submitted his plan to overhaul coverage for the 400,000 low-income residents who qualified under Medicaid expansion, but it’s unclear if the Obama administration will approve it or how strong the political blowback would be for ending the program. On Aug. 24, Bevin, a Republican, turned in a long-awaited waiver application to the federal Department of Health and Human Services. The plan would provide stricter rules for beneficiaries who qualify but many of the proposed items are likely to be met with skepticism from the Obama administration. If the federal government does not budge on major conservative priorities such as work requirements and lock-out periods, Bevin has threatened to pull the plug on expansion altogether. Bevin has been keen to overhaul the program with a more conservative edge. His proposed changes include requiring beneficiaries to work or volunteer, a request that the Obama administration has denied for multiple states with similar wishes. Advocates have been troubled by the Bevin administration’s call for six-month lockout periods for beneficiaries who fail to make on-time payments or fill out Medicaid paperwork correctly. The plan also would allow consumers to use health savings accounts and receive dental and vision care if they practice specific healthy habits.

Hospital Group Sees Kickback Risk in Medicare Payment Change

Medicare officials are implementing an order to stop paying higher rates for care provided at new satellite doctors’ offices affiliated with hospitals. Last year’s budget deal (PL 114-74) directed Medicare to instead reimburse the new off-campus offices under the less-generous physician fee schedule or reimbursement rates for ambulatory surgical centers. Existing off-campus departments could continue to bill under the hospital outpatient rule. Lawmakers had the backing of many policy analysts for a provision that addresses a longstanding concern about unequal Medicare pay. The federal health program for senior citizens and the disabled could pay $492 for an echocardiogram performed in a doctor’s office classified as a hospital outpatient facility, but only $228 for the same service in a physician-owned office, the Medicare Payment Advisory Commission said in a report to Congress. The Congressional Budget Office estimated $9.3 billion in savings over a decade from including the provision on hospital outpatient departments in the budget deal. The newer satellite offices thus would face administrative limbo, with CMS signaling that it may develop a new pay system for them after 2017. The hospital outpatient departments (HOPDs) that opened, relocated or changed service lines after Nov. 2, 2015, also would assume substantial new legal risks, including the potential cost of defending against whistleblower suits.

Medicare Says $466 Million Saved in Alternative Pay Programs

Federal officials highlighted token Medicare savings as evidence of the success of alternative reimbursement tests, which are meant to lay the groundwork for a broader overhaul of how the nation’s single largest purchaser of health care pays for services. Savings rose to $466 million last year from $411 million the previous year from certain programs meant to tie Medicare payments to judgments about the quality of care. These are the combined results of 392 accountable care organizations (ACOs) participating in Medicare’s Shared Savings program and the dozen in what’s known as the Pioneer Accountable Care model. The savings represent only a sliver of Medicare’s roughly $600 billion in annual spending. These programs are among the most advanced tests done of alternative payment models by CMS. The results seen to date may yield clues about how doctors and other medical professionals and health organizations will fare as Medicare increasingly ties its payments to judgments about the quality of care provided. The agency is in the midst of creating a new framework for assessing medical care that was mandated by last year’s overhaul of Medicare physician payment. CMS also is working on a new unified payment approach for what’s called post-acute care, a roughly $60 billion expense for Medicare to cover services provided to people recovering after strokes and serious illnesses and surgeries.

Aetna Withdraws Obamacare Exchanges in 11 States

Health insurer Aetna Inc. announced late Monday it will largely withdraw from state exchanges set up under the 2010 health care overhaul, citing financial losses it attributes in part to a controversial premium stabilization program the law established. Aetna’s exodus from 11 state-based exchanges comes after a more dramatic 30-state withdrawal by UnitedHealth, the nation’s largest health insurer. The departures will reduce the market competition that authors of the health law. The decisions moreover underscore just how volatile the individual insurance market remains, three years after the exchanges were launched. Major health plans including Anthem Inc. and Humana Inc. have said that they, too, expect losses but have not said they plan to withdraw. Other insurers such as Cigna Corp. and Medicaid-focused plans like Molina Healthcare and Centene Corp. have said they are profiting from that part of their business. Earlier this year, even Aetna said it saw participation as a good investment.

Medicaid Expansion Didn’t Alter Overall ER Use, Study Finds

The health care overhaul’s Medicaid expansion didn’t significantly alter the overall use of hospital emergency rooms, according to a new Health Affairs study that suggests newly insured individuals don’t visit ERs more frequently. The study found that from 2012 through 2014, overall emergency department use differed by less than 1 percent between states that expanded their Medicaid programs and those that opted out. Some 17 million people gaining coverage through private insurance and expanded Medicaid, the joint health insurance for the poor and disabled. Researchers used monthly emergency department data from 478 hospitals. The authors noted some limitations, including that the number of hospitals assessed only represented about 10 percent of ERs nationwide. They also were not capable of distinguishing which patients had new insurance. And they were unable to track the longe-term effects of expansion. Emergency rooms in expansion states saw a 25.5 percent increase in Medicaid beneficiaries between 2012 and 2014 while non-expansion states saw a 1.7 percent increase. Among private insurance policy holders, researchers found a 1.3 decrease in emergency room use in expansion states while non-expansion states saw a 7.1 percent increase. Between expansion and non-expansion states there was a 6.7 percent overall decrease in visits paid by private insurance. Researchers said that may have been attributable to some policyholders becoming Medicaid-eligible under expansion and moving into the program.

Surgeon General Letter on Opioid Epidemic

The Office of the Surgeon General is sending a letter on the opioid epidemic to nearly 2.3 million physicians and other health professionals. The letter is a call to action on safe prescribing education, access to treatment for opioid use disorder, and compassionate care without stigma. The letter is available here.