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Federal Update From CMA (Sept. 30, 2016)

October 14, 2016 CMA, GPCI, MACRA GPCI, MACRA 0

SUMMARY

  1. MACRA Update
  2. Budget Update
  3. Medicare California GPCI Locality Reform Transition Plan
  4. Medicare 2017 Physician Fee Schedule Regulation
  5. Medicare Regulations Governing Meaningful Use, Ambulatory Surgery Centers, and the Elimination of the Site of Service Payment Rate Differential
  6. Department of Education Medical Student Public Service Loan Forgiveness Program

I. MACRA Update: Final Rule Due Before November 1, 2016

The Centers for Medicare and Medicaid Services (CMS) are preparing to release the final rule to implement the Medicare Access and Children’s Health Reauthorization Act (MACRA) payment changes. It is expected to be out before November 1, 2016.

CMA is working with AMA and others to prepare for the final rule. CMA will be hosting education programs and webinars and will have educational materials ready once the rule is released and analyzed. Both CMS and AMA are preparing to release navigation tools to help physicians determine the most appropriate measures for their practices that will maximize reimbursement and successful reporting. CMA will also continue its advocacy efforts to reduce the burdensome reporting programs and penalty structure.

CMA has created a MACRA Resource Center on the CMA website www.cmanet.org/MACRA.

In addition to providing CMA information, it contains links to the CMS information, extensive AMA resources, including the STEPS Forward program, and additional resources provided by the national specialty societies, with information about their clinical data registries. The specialty society clinical data registries have helped thousands of physicians successfully report under the Medicare PQRS quality and Meaningful Use programs. Also listed on the CMA website are “STEPS PHYSICIANS CAN TAKE NOW TO PREPARE FOR MACRA.”

II. Budget Update: Government Shutdown Avoided, Zika Virus Funded

Congress narrowly escaped another budget deadline to avoid a government shutdown. On September 28th, Congress adopted a stop-gap measure to fund the federal government at current levels through the first week in December 2016. They also finally agreed on a measure to provide $1.1 billion in funding to combat the Zika virus. With more than 3,358 Zika cases in the U.S. (mostly from people who acquired the virus abroad) and another 19,777 cases in the U.S. territories, the money will go towards public health initiatives, vaccine research, and mosquito control. The package also included public health funding assistance for the residents of Flint, Michigan who were exposed to contaminated water.

III. Medicare California GPCI Locality Reform Transition Plan Starts in 2017

CMA submitted comments in support of the Centers for Medicare and Medicaid Services (CMS) proposed plan to implement the “California GPCI Fix” which reforms the Medicare physician geographic payments in California. In 14 California counties, physicians had been underpaid by up to 14% per year because the payment regions were so outdated. Starting in 2017, all Medicare physician payment localities will be transitioned to Metropolitan Statistical Areas (MSAs) so that Medicare will more accurately pay physicians based on their local costs to provide care. It also aligns California’s physician payment regions with the Medicare hospital regions. Payment updates for the 14 counties will be phased-in over six years. Physicians practicing in rural regions will be held harmless from payment reductions after 2017.

CMA applauded CMS’ implementation plan as accurate and thorough. CMA GPCI experts, Drs. Larry DeGhetaldi and Ned Bentley, reviewed the county data files and verified all of the CMS calculations. Despite the accuracy of the data, the payment impact chart that CMS published in the proposed rule was wrong. CMA urged CMS to publish a corrected chart as soon as possible. The CMA-corrected payment impact chart by California region is in the CMA letter to CMS attached.

CMA opposes national practice expense payment reductions. Unfortunately, the proposed 2017 Medicare Fee Schedule includes GPCI practice expense reductions for physicians across the nation which offsets the increases many California physicians are receiving because of the California reform. According to the CMS-proposed 2017 Medicare Physician Fee Schedule, the malpractice and practice expense components of the Geographic Practice Cost Index (GPCI) went down in nearly every region in California, which will result in an average .48% GPCI payment reduction in all but a few regions of California. This reduction is not the result of the California locality reforms outlined above. CMA finds it unfathomable that California physicians and other national urban areas would be taking a pay cut in 2017 because practice expenses decreased. CMA urged CMS to verify the data, to use commercial rent data rather than residential rent data, and to increase the low 8% weighting of the physician office rent component of the practice expense GPCI, since office rent is such a large component of California physician practice costs.

IV. 2017 Proposed Medicare Physician Fee Schedule

CMA submitted lengthy comments to CMS on the proposed 2017 physician payment rule on September 6, 2016. CMA fully supported the AMA’s comments. Below is a summary of the CMA/AMA comments.

  • The CMA fully supports and endorses the recommendations and comments of the AMA/Specialty Society RVS Update Committee (RUC) regarding physician work, practice expense, and malpractice relative value units (RVUs) for particular services, the process and methodology for valuing services, and the RUC’s additional comments on other issues in the proposed rule.
  • The CMA is opposed to the CMS proposal to collect data on the post-operative visits and resources used in furnishing global services, and urges CMS not to finalize this proposal, but to work with stakeholders, including the AMA and the RUC, to develop a more reasonable solution. The current proposal will create an undue burden on physicians and reduce physician payment accuracy.
  • The CMA supports the addition of new telehealth codes and urges CMS to finalize the rule to expand coverage of telehealth as proposed.
  • The CMA supports the CMS proposals to improve payment accuracy for primary care, care management, and patient-centered services. Specifically, we support a separate payment for non-face-to-face prolonged Evaluation and Management (E/M) services, separate payments for services furnished using the Psychiatric Collaborative Care Model (CoCM), the implementation of other codes in the CPT family of Chronic Care Management (CCM) services, and a separate payment to recognize the work of a physician in assessing and creating a care plan for beneficiaries with cognitive impairment. We also applaud CMS’ proposals to simplify Chronic Care Management codes for physicians.
  • The CMA opposes the CMS plan to eliminate the 2017 physician payment increase Congress provided in MACRA, in order to fund an add-on payment for services provided to patients with mobility-related disabilities.
  • The CMA strongly supports the CMS proposal to expand the duration and scope of the Diabetes Prevention Program (DPP) model with the establishment of the Medicare DPP.
  • Consistent with the impacted national specialty societies and AMA, CMA believes full scale Appropriate Use Criteria (AUC) implementation should be delayed to January 1, 2019 and should be phased in over time, starting with a list of conditions that could be tailored for each specialty.
  • The CMA has serious concerns with the CMS proposed changes to the quality measures used to assess Accountable Care Organization (ACO) performance.
  • The CMA urges CMS to ensure the Medicare Shared Savings Program (MSSP) is aligned with the MACRA Quality Payment Program (QPP) by allowing ACOs to use health information technology in ways that most effectively meet the needs of their patient population.
  • The CMA strongly supports the CMS proposal to incorporate a voluntary patient choice process into the ACO assignment methodology.
  • The CMA supports the CMS proposal to provide greater transparency to the Medicare Part D prescription drug benefit by releasing pricing information and Part C Medical Loss Ratio (MLR) data.

V. Additional Medicare Regulations Governing Meaningful Use, Ambulatory Surgery Centers, Removal of the Pain Measures From the Hospital Program, and Elimination of the Site of Service Differential Payments

On September 6, 2016, CMA submitted extensive comments on a final set of Medicare regulations. CMA fully supported the AMA comments. A summary of the CMA/AMA comments are listed below.

  • CMA supports the CMS proposal to eliminate the site of service payment differential between physician offices and off-campus provider-based departments formed after 2017. This proposal may help preserve small, independent practices by eliminating the incentive for hospitals to purchase physician practices.
  • CMA supports the CMS proposed provision allowing physicians to report Meaningful Use for 90 days in 2016. We also commend CMS for developing a hardship exception that allows first time Meaningful Use participants to report once in 2017 to satisfy both Meaningful Use and the Advancing Care Information performance category in MACRA.
  • CMA supports the CMS proposal to remove pain measures from the Hospital Value-Based Purchasing Program (VBP).
  • CMA is extremely concerned about the CMS proposed continuation of the large gap between payments in hospital outpatient departments and ambulatory service centers. CMS should increase ambulatory surgical center (ASC) rates to eliminate this disparity.

VI. Department of Education Medical Student Public Service Loan Forgiveness

CMA continues to press the Department of Education to fix the regulation that inappropriately excludes California physicians who provide care in non-profit hospitals and clinics from the public service student loan forgiveness program. Physicians in every state except California and Texas are afforded loan forgiveness. The Department erroneously crafted the implementing regulation mandating that physicians be fully employed to receive forgiveness. This is inconsistent with the statute passed by Congress and excludes physicians in states with bans on the corporate practice of medicine. Leader Nancy Pelosi (D-SF) has taken the lead in negotiating with the Administration on behalf of California physicians. Because we are running out of time to promulgate full regulations during the remaining weeks of the Obama Administration, we have proposed that the Department issue a guidance to its loan servicers to provide loan forgiveness to California and Texas physicians who have worked an average 30 hours/week for ten years (current law) in a non-profit hospital with an open medical staff, or non-profit clinic or foundation. The first student loan forgiveness applications will be accepted in October 2017.



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