Need guidance on how to successfully report PQRS measures and avoid future Medicare payment adjustments? Check out the NASS Performance Measurement Committee’s guide, “Navigating CMS Quality Initiatives: Avoiding Penalties.”
SENATORS REQUEST STAKEHOLDER INPUT ON TRANSPARENCY: Senate Finance Committee Chairman Ron Wyden (D-OR) and Senator Charles Grassley (R-IA) sent a joint letter to provider stakeholders last week, requesting feedback on enhancing the availability of health care data. The Senators said in their letter that while great strides have been made by federal and state entities to increase transparency and utilize health data more efficiently, that more still can be done to reach its full potential. Health providers, including physicians, are encouraged to provide comments, as the two Senators would like physicians to play a greater role in the process. Comments are due on August 12, 2014. For more information, please click here.
LOUISIANA PASSES LAW TO CLOSE ACA GRACE PERIOD LOOPHOLE: Louisiana became one of the first states to pass a bill into law last month that requires insurance companies to address the Affordable Care Act’s (ACA) “grace period” loophole. The bill, HB 506, requires that “if the qualified health plan issuer informs the physician or other health care provider or his representative that the enrollee is eligible for services but not that the enrollee is in the grace period, the determination shall be binding on the qualified health plan issuer, and it shall pay the claims for covered services.” Currently, qualifying health plans in an exchange must offer a three-month grace period to enrollees who receive advance payments for premium tax credit. If an enrollee receives services from a provider, but fails to make a payment for the second or third month during that period, insurance companies are not required to notify providers of a missed payment, leaving providers to incur the cost of services provided.
SENATE CONFIRMS BURWELL AS NEXT HHS SECRETARY: Last week, the U.S. Senate voted overwhelmingly (78-17) to confirm Sylvia Mathews Burwell as the next Secretary of the Department and Health and Human Services. Despite their grievances over the Affordable Care Act (ACA), Senate Republicans said that their support for Burwell is a result of her acknowledgement of what is wrong with the ACA and her pledge to respond to Congressional inquiries in a timely manner.
BI-PARTISAN HEALTH BILL EMERGES FROM VA SCANDAL: Senators John McCain (R-AZ) and Bernie Sanders (I-VT) reached a deal this week on legislation that addresses long wait times and would recruit more medical professionals to VA hospitals. The Veteran Access to Care Act (H.R. 4810) would provide an additional $500 million to the VA program, which would be used to hire more doctors and nurses, open more region VA hospitals, and allow veterans experiencing wait times greater than 14 days OR living more than 40 miles away from a VA facility, to be seen by outside providers. Currently, the VA has a shortage of 400 physicians and the bill would incentivize physician participation by offering doctors and nurses a one-time bonus for joining the VA. A section-by-section summary of the bill can be found here.
REPORT SAYS SURGEONS “MISSING” FROM ACOs: A recent study released by Health Affairs says that low surgeon participation rates in accountable care organizations (ACOs) is attributable to little devotion by program administrators to include surgeons into the models. The report finds instead that ACOs are generally geared toward primary care physicians and those who treat patients with chronic care conditions, such as diabetes. While the demand for a high quality, low cost alternative payment system is widespread among many Members of Congress, the study adds to the claims made by NASS and other specialty societies that – at least for now – ACOs are simply not are an appropriate alternative payment model for all spine care providers.
HHS OIG EXPECTS TO RECOVER BILLIONS IN 2014: The Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued its semi-annual report to Congress announcing that it would recover an estimated $3.1 billion in improper payments and fraudulent activities for the first half of this year. The report referenced a 2013 OIG study that said “surgeons performed more spinal surgeries at hospitals that purchased from PODs, and those hospitals experienced increased rates of growth in the number of spinal surgeries performed in comparison to the rate for all hospitals.”
WHITE HOUSE ADVISORS SAY FFS BARRIER TO IMPROVING CARE: Recently, the President’s Council of Advisors on Science and Technology (PCAST), said in a report that Fee-For-Service (FFS) is a major barrier to improving health related outcomes for beneficiaries and is a major driver of costs in the Medicare program. Among the recommendations, the council urged HHS to “convene public and private payers (including Medicare, Medicaid, State programs, and commercial insurers) and employers to discuss how to accelerate the transition to outcomes based payment, promote transparency, and provide tools and supports for practice transformation.”
GAO SAYS SELF-REFERRAL FOR PHYSICAL THERAPY DOWN: Last week, the Government Accountability Office (GAO) released a report on self-referrals related to physical therapy (PT). The report was generally positive, as it found that from 2004 to 2010, non-self-referred PT services increased at a faster rate than self-referred PT services. NASS has been tracking this issue over concerns about the efforts to eliminate the in-office ancillary services exception (IOASE) to the Stark Law on the federal/state levels. The full report can be accessed here.
GAO ANNOUNCES NEW MEDPAC MEMBERS:On May 29, the GAO announced the appointment of three new members to the Medicare Payment Advisory Commission (MedPAC). The appointed members are Kathy Buto, MPA; Francis “Jay” Crosson, MD, Group Vice President, American Medical Association in Chicago, Illinois; and Warner Thomas, MBA, President and CEO of the Ochsner Health System in New Orleans, Louisiana. MedPAC advises Congress on payments to providers in Medicare’s traditional fee-for-service programs.
SGR UPDATE: During a Senate Finance committee confirmation hearing last week, Sylvia Mathews Burwell, the President’s nominee for Secretary of the Department of Health and Human Services (HHS), said she is looking forward to working with the committee to permanently repeal the sustainable growth rate formula (SGR). Burwell, who is expected to be confirmed, said she was excited for the prospects of repeal this year and cited the bipartisan legislation that was previously passed by the key health care committees in Congress.
While Congressional efforts to repeal the SGR are at a virtual standstill, sources inform NASS that House leadership is still optimistic that a deal can be made during Congress’ lame duck session. Other sources have indicated that key Republican Senators have been meeting with House Republican leadership to discuss the prospects of using Overseas Contingency Operation Funds (OCO) as a viable option to pay for SGR repeal. NASS will continue to provide any updates on new developments as they become available.
BIOSIMILAR BILL HEADS TO DE GOVERNORS DESK: Last week, the Delaware state legislature passed Senate Substitute 1 for SB 118, which requires pharmacists to notify treating physicians if another version of a biologic medicine is being substituted for the version prescribed by the doctor. NASS joined the Alliance of Specialty Medicine (The Alliance) in sending a letter of support for this legislation to the Delaware general assembly, stating that the bill will help ensure proper patient care. The Alliance will send a letter urging Delaware’s Governor to sign the bill into law.
SENATORS INTRODUCE BILL TO LIMIT AUTHORITY OF SECRETARY OF HHS: Last week, Senators Tom Coburn, MD (R-OK), John Barrasso, MD (R-WY), Rand Paul, MD (R-KY) and John Boozman, OD (R-AR), introduced, S. 2278, the Safeguarding Care of Patients Everywhere Act (SCOPE ACT). This legislation aims to protect the physician-patient relationship endangered by repealing section 1311(h) of the Affordable Care Act (ACA). According to the Senators, this provision grants the authority to the Health and Human Services Secretary to determine whether a doctor is providing “quality health care measures” and can prohibit health insurers from working with medical providers who don’t meet Secretary-established criteria for quality. This Senate bill is a companion to a House bill that was previously introduced by Rep. Phil Gingrey, MD (R-GA). At this time there is little legislative activity to report; however, NASS will continue to monitor this legislation and provide any updates as they become available.
The health care industry is moving at a fast pace where health care providers and their patients continue to strive for guidance and additional support from specialty societies. Current NASS practice has been reactively responding to requests from various insurance companies by sharing our expert opinions in reviewing coverage policies. However, in June 2012, to meet the complexity of the health delivery system and ongoing demands of NASS members and their patients, the NASS Board of Directors approved the formation of a multi-specialty team to proactively develop credible and reasonable coverage recommendations for NASS to share with payors, patients and spine care providers. The group determined the topics, from therapeutic to diagnostic procedures including non-operative, interventional, and surgical procedures. NASS reviewed and selected topics that represent a wide variety of frequently-used care tools.
In May 2014, after more than a year of rigorous scientific literature review, drafting and editing, NASS approved its first set of coverage recommendations. NASS has recently published these 13 coverage recommendations (https://www.spine.org/Pages/PolicyPractice/Coverage/CoverageRecommendations.aspx) with a plan to publish more in coming months.
These coverage recommendations use an evidence-based approach to spinal care where possible. In the absence of high-level data, policies reflect the multi-disciplinary experience and expertise of the committee members in order to present reasonable standard practice indications in the United States.
It is our strong intent and vision that insurance providers and their patients will utilize these coverage recommendations as a reference to guide appropriate coverage decisions and to guard against inappropriate denial of quality spinal care.
NASS coverage recommendations will be revised periodically based on the availability of new evidence-based literature and the feedback we receive from interested parties. For more information on NASS’ coverage activities, please contact us at firstname.lastname@example.org.
In 2013, NASS joined more than 50 medical specialty societies participating in ABIM Foundation’s Choosing Wisely campaign. This campaign encourages active discussion between physicians and patients about the most appropriate care, based on the patient’s situation and the very latest in research and treatment. Specialty organizations were asked to explore the necessity of tests and procedures within their field and create lists of “Things Physicians and Patients Should Question.”
Daniel Wolfson of ABIM Foundation recently wrote an essay in response to an article that questioned the merits of the Choosing Wisely initiative. The response lauds the leadership of the specialty organizations and examines the interconnectedness of the health care system that lead to the lists. Wolfson states the project is important for reducing waste in a time of waning health care resources, and asserts that improvements can only be made by having these discussions with health care stakeholders, physicians and patients.
SENATE SENDS SHORT-TERM SGR FIX TO PRESIDENT’S DESK:On Monday, the United States Senate voted 64-35 in favor of delaying cuts to Medicare physician reimbursements for one year as a result of the sustainable growth rate (SGR) formula. The bill, Protecting Access to Medicare Act of 2014, is identical to H.R. 4302 passed in the House of Representatives last week, was signed into law by the President. The bill received heavy criticism from physician groups as it allows the Centers for Medicare and Medicaid (CMS) to identify misvalued codes used under the Medicare Physician Fee Schedule. This provision is expected to cut $5 billion from the physician fee schedule over three years beginning in 2017 and will be used to partially offset the cost of the yearlong patch.
WHAT’S IN THE BILL: The short-term fix prevents the scheduled 24 percent cuts to physician’s Medicare reimbursements on April 1 and contains a positive 0.5 percent update for physicians through December 2014. Then, beginning in January 2015, physicians will receive a 0.0 percent update until the end of March 2015 when the patch will yet again expire. While the majority of medical groups had opposed this legislation, physicians earned a one-year delay of ICD-10 implementation, which was previously set to take effect this October. Other provisions in the bill include:
- establishing a program for appropriate use criteria on certain imaging services;
- delaying “two-midnight” rule for inpatient reimbursements through June 2015;
- delaying recovery audits (RAC) on unnecessary claims through March 2015.
OUTLOOK DOES NOT FAVOR REPEAL THIS YEAR: Despite the recent vote, leaders in the House and Senate said that passage of a short-term SGR fix doesn’t preclude Congress from passing full repeal and replacing legislation before the end of the year. However, considering the proximity to this November’s mid-term elections, and the traditionally inactive lame duck season that follows, the prospects of repealing the SGR this year are very slim. NASS will continue to urge members of Congress to work together to pass the previously agreed upon bi-partisan, bi-cameral SGR repeal legislation as the negotiations over offsets continue.