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September 2017

CMS Issues Proposed Rule Modifying Episode Payment Models
The Centers for Medicare & Medicaid Services (CMS) released a proposed rule August 15 that would eliminate the Episode Payment Models (EPMs), including acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes of care. It also would eliminate the cardiac rehabilitation (CR) incentive payment model. CMS said many providers already are engaged in voluntary initiatives with the agency; therefore, requiring hospitals to participate in EPMs is inappropriate. The proposed rule also revises aspects of the Comprehensive Care for Joint Replacement (CJR) model. CMS proposes to make participation in the CJR model voluntary for all hospitals in certain Metropolitan Statistical Areas (MSAs) and for low-volume and rural hospitals in all of the MSAs included in the program. In addition, CMS proposes to increase the pool of eligible providers that qualify under the Advanced Alternative Payment Model (A-APM) track of the CJR model. The proposed rule and a fact sheet on its CJR participation requirements are available for public review.

Where Health Care Reform Stands
Leadership on both the Senate Finance Committee and Senate Health, Education, Labor, and Pensions (HELP) Committee announced that they would hold hearings on health care reform following August recess. HELP Committee hearings will begin the week of September 4, and will focus on stabilizing the insurance market. Witnesses will include state insurance commissioners, patients, governors, health care experts, and insurance companies. Chairman Lamar Alexander (R-Tenn.) stated that he has discussed a bipartisan market stabilization bill with his panel. He also supports the continuation of cost-sharing reduction payments by the President through September, followed by a yearlong appropriation by Congress. The President and Secretary of the U.S. Department of Health and Human Services (HHS) met with Sen. Bill Cassidy (R-La.) to discuss his proposal to give block grants to states in an amount equal to what the federal government currently spends on the Affordable Care Act (ACA). In the House, a bipartisan group of lawmakers are discussing a health care reform plan that would pay for cost-sharing reduction payments, alter the law’s employer mandate, and eliminate the impending tax on medical devices. Members on both sides of the aisle, along with stakeholders and experts, agree that cost-sharing reduction payments are necessary to ensure stability in the individual marketplace. Senate leadership continues to stress that it will not bring up health care legislation again until they can guarantee 50 votes, but state that health care reform proposals continue to be scored at the Congressional Budget Office (CBO).

Senate Reauthorizes FDA User Fee Programs
The Senate passed the Food and Drug Administration Reauthorization Act (FDARA). H.R. 2430 extends for five years the FDA’s authority to collect $400 million in user fees from drug and medical device companies to fund the new product approval process. The Senate also passed the Trickett Wendler Right to Try Act (S. 204) by unanimous consent. President Trump signed the FDARA.

VA Choice Program Continues
The Senate cleared legislation to fund the Veterans Choice Program last week. S. 114 will provide $2.1 billion to continue funding the program, which was projected to run out of money in mid-August. The bill passed the House of Representatives in July. The Department of Veterans Affairs also announced the creation of three programs aimed at modernizing health care for veterans. Veterans will have access to a new a new scheduling system via mobile phones, as well as additional care for the homebound. The $1 billion budget for telehealth will remain the same. President Trump approved the legislation during his working vacation.

Opioid Crisis Designated National Emergency
The President classified the opioid crisis as a national emergency. Based on the recommendations from the President’s Commission on Combating Drug Addiction and the Opioid Crisis interim report, the White House instructed federal agencies to use any appropriate emergency and other authority to respond to the epidemic. Secretary Price stated that ensuring widespread access to overdose reversing medication as well as review of opioid alternative painkillers by the Food and Drug Administration (FDA) are two priorities for the Administration. The Department is also examining privacy regulations to determine whether they can be made less onerous in cases of an overdose. The White House stressed that it is working to stop the movement of fentanyl into the U.S. and to increase federal drug prosecutions. It is also looking at ways to reduce the number of pills prescribed and the length of painkiller prescriptions

ONC to Hold Meetings on Interoperability
The Office of the National Coordinator (ONC) plans to hold two stakeholder forums before the end of the year focusing on a nationwide framework for electronic health-data exchange. Full adoption of interoperability is a high priority for the ONC, particularly in order to support providers participating in value-based payment programs. The first meeting is likely to be scheduled before the end of September.

HELP Committee Begins Marketplace Stabilization Hearings
The Senate Health, Education, Labor, and Pensions (HELP) Committee scheduled for the insurance commissioners about “Stabilizing Premiums and Helping Individuals in the Individual Insurance Market for 2018.” Insurance commissioners Mike Kreidler from Washington, Julie Mix McPeak from Tennessee, Teresa Miller from Pennsylvania, John Doak from Oklahoma, and Lori Wing-Heier from Alaska are scheduled to appear. On September 7, a panel of governors will testify on the same subject. Witnesses will include Colorado Gov. John Hickenlooper, Massachusetts Gov. Charlie Baker, Utah Gov. Gary Herbert, Montana Gov. Steve Bullock, and Tennessee Gov. Bill Haslam. According to Chairman Lamar Alexander (R-Tenn.) and Ranking Member Patty Mur (D-Wash.), the HELP Committee plans to hold additional bipartisan hearings on the individual insurance market later in the year. The Committee is working to draft a stabilization package by mid-September, which it hopes to pass by the end of the month.

CMS Releases FY 2018 IPPS Final Rule
The Centers for Medicare & Medicaid Services (CMS) released the fiscal year (FY) 2018 Medicare Inpatient Prospective Payment System (IPPS) final rule August 2. The rule updates next year’s Medicare payment rates and coverage policies for patients when they are discharged from a hospital. CMS projects that implementation of provisions in the final rule will lead to an approximately $2.4 billion increase in Medicare spending on inpatient hospital services in 2018. CMS will distribute more than $6 billion in uncompensated care payments to acute care hospitals. CMS also finalized modifications to the clinical quality measures (CQMs) reporting requirements under the Medicare and Medicaid Electronic Health Record (EHR) Incentive Program. As a result of these changes, eligible hospitals that participate only in the EHR Incentive Program or participate in both the EHR Incentive Program and the Hospital Inpatient Quality Reporting Program will be required to report on at least four self selected CQMs. In addition, CMS finalized its proposal to direct Medicare audit contractors to make the critical access hospital (CAH) 96-hour certification requirement, which mandates that physicians certify that a patient may reasonably be expected to be discharged or transferred from a CAH within 96 hours of admission—a low priority for medical record reviews. Absent concerns of fraud, waste, or abuse, hospitals should not expect to receive medical record requests related to the 96-hour requirement from auditors. The final rule is available for public review, along with a fact sheet on its payment and quality aspects.

GOP Agenda for Post-August Recess
Republican leadership in the House of Representatives has outlined their legislative priorities for when Congress returns from August recess on September 5. They plan to tackle a spending package covering the eight remaining appropriations bills that have yet to be passed. If successful, this package would be combined with the four-bill “minibus” the House passed earlier in the year. The minibus included funding for the Department of Defense and other security-related bills. The 12-bill omnibus would then be sent to the Senate which has not yet passed any appropriations bills. Lawmakers must act to fund the government by the end of the fiscal year (FY), September 30. The House has only 12 days in session during the month of September and the Senate has 17 days scheduled. Lawmakers will also have to address the debt limit increase before the end of September and House Republicans hope to pass a FY 2018 budget, which tax reform. Reauthorization of the Children’s Health is also on the agenda. Funding for CHIP expires on September 30.

CMS Releases New Education Materials on Social Security Number Removal Initiative
The Centers for Medicare & Medicaid Services (CMS) launched a new web page to educate providers about the Social Security Number Removal Initiative (SSNRI). The SSNRI is a fraud-prevention effort that involves removing SSNs from Medicare insurance cards to combat identity theft and illegal use of Medicare benefits. The new Medicare cards will feature randomly assigned numbers, known as Medicare Beneficiary Identifiers (MBIs), in place of beneficiaries’ existing SSN-based Health Insurance Claim Number (HICN), which is used to track Medicare billing, eligibility status, and claims status. CMS will replace all Medicare cards by April 2019. Beginning January 1, 2020, CMS will no longer accept HICNs and providers must use MBIs to check Medicare eligibility, submit claims, and file appeals. CMS advises providers to take the following five steps to prepare for the new Medicare cards:

  • Visit CMS’ provider website and sign up for the weekly Medicare Learning Network (MLN) Connects newsletter to receive updates on the initiative.
  • Attend CMS’ quarterly calls to get more SSNRI information. CMS will let providers know when calls are scheduled in the MLN Connects newsletter.
  • Verify all Medicare patient addresses. If the addresses on file differ from the Medicare address listed on electronic eligibility transactions, providers should ask patients to contact the Social Security Administration and update their Medicare records.
  • Work with CMS to help Medicare patients adjust to their new Medicare cards. CMS will make available posters and other materials that providers can share with patients to help them learn about SSNRI-related changes.
  • Test system changes and work with billing office staff to ensure they are ready to use the new MBI format.