June 26, 2014
National UpdateAMA urges prompt federal action to provide access to care for VA patients
The AMA outlined recommendations on pending legislation to ensure eligible veterans receive timely, quality health care outside Veterans Affairs (VA) facilities as needed.
The June 19 AMA letter (AMA login required) to the House Committee on Veterans' Affairs and letter (AMA login required) to the Senate Committee on Veterans' Affairs offer recommendations for resolving differences between the two bills—H.R. 4810, "The Veteran Access to Care Act of 2014," and S. 2450, "The Veterans' Access to Care through Choice, Accountability and Transparency Act of 2014" (which passed the Senate as H.R. 3230).
AMA recommendations included ensuring adequate payments for services and treatment and removing provisions that would create unnecessary administrative burdens for participating physicians.
The AMA also on June 10 sent a letter to President Obama (AMA login required), urging his administration to take steps to provide prompt access to care outside the VA system.
Physicians are stepping into action in response to the access-to-care crisis for the nation's veterans, offering their services until the U.S. Department of Veterans Affairs (VA) health care system can provide health care in a timely fashion. Two states already have developed physician registries.
The Texas Medical Association has created a registry of physicians who are willing to see veterans in their practices. The registry will be shared with community groups that work with veterans and medical directors of VA facilities in the state. Physicians in the Empire State, meanwhile, can be part of a registry coordinated by the Medical Society of the State of New York.
Physicians in other states will be looking to their state and county medical associations to develop similar registries that can help them serve veterans in need of care.
Speaker of the AMA House of Delegates Andrew Gurman, MD, last week participated in a summit convened by the White House Office of National Drug Control Policy (ONDCP) to discuss abuse of prescription drugs and heroin.
Featured speakers included Attorney General Eric Holder, ONDCP Acting Director Michael Botticelli, National Institute on Drug Abuse Director Nora Volkow, MD, and Vermont Governor Peter Shumlin. Importantly, all summit speakers focused on public health approaches to addressing drug abuse. The AMA will follow up with the ONDCP on ways the association can further assist federal and state government efforts to prevent abuse, diversion, overdose and death.
The AMA offers a variety of resources to help prevent prescription drug abuse, including a series of archived webinars offered through the Providers' Clinical Support System for Opioid Therapies.
The AMA has joined a number of medical specialty societies and patient advocacy organizations in calling for the Centers for Medicare & Medicaid Services (CMS) to withdraw guidance it issued to Medicare Part D prescription drug plans that indicates they should require prior authorization before covering drugs for patients who enter hospice care.
The guidance seems intended to prevent Medicare from paying twice for prescription drugs by including their costs in the payments made to hospice providers and also covering their costs under Part D. While hospice care is supposed to include the costs of drugs for the terminal illness and related conditions, such as pain, Part D coverage is supposed to continue for drugs that are not related to the patient's terminal condition.
The joint letter (AMA login required) to CMS Administrator Marilyn Tavenner expresses serious concerns that dying patients will lose access to necessary medications for conditions they have had long before their terminal conditions.
A June 18 hearing of the House Committee on Ways and Means Health Subcommittee examined a report released earlier this month by the Medicare Payment Advisory Commission (MedPAC) that looks at Medicare's policies across its three payment models.
The report compares Medicare's policies on payment, risk adjustment and quality measurement, among other issues, across traditional fee for service, Medicare Advantage and accountable care organizations. MedPAC is concerned that the differing payment rules and quality measures for the three models produce different levels of program support and impede efforts to compare quality across Medicare.
Health Subcommittee Chairman Kevin Brady, R-Texas, expressed concern about Medicare's long-term financing challenges. Brady noted that the strain of the Part B program soon will be felt; per capita spending is more than three times what a beneficiary contributes over his or her lifetime. Brady also emphasized the need for beneficiaries to have an "apples-to-apples" comparison of cost and quality across the three payment models and stressed the importance of Medicare payment accuracy.
New recommendations by the Medicare Payment Advisory Commission (MedPAC) offer guidance for how the Centers for Medicare & Medicaid Services (CMS) attributes patients to accountable care organizations (ACO) under the Medicare Shared Savings program.
The recommendations, which the commission made in response to physician concerns raised during a meeting with the AMA and several medical specialty societies, urges the agency to move to a system that would permit most specialists to participate in multiple ACOs. Under current rules, CMS attributed patients to a particular ACO through a two-step process that effectively has made it impossible for most physicians—including specialists—to participate in more than one ACO.
An AMA-formed coalition of affected specialties attempted to resolve the issue in repeated meetings with CMS and then took the issue to MedPAC. Under the commission's plan, primary care physicians still would be exclusive to one ACO, but other specialists would be exclusive only if an ACO identified the specific physician by both his or her Tax Identification Number and National Provider Identifier.
The recommendations also call on CMS to:
- Move to prospective rather than retrospective attribution
- Replace the many process-based ACO quality measures with a small set of population-based outcome measures
- Retain the one-sided risk model for new ACOs but require two-sided risk in future contracts
- Give ACOs the flexibility to waive certain Medicare requirements, including the three-day hospital stay that now is a condition of Medicare coverage for care in a skilled nursing facility
- Clarify the guidelines for communications ACOs can have with patients regarding the advantages of participation in the ACO
- Permit ACOs with two-sided risk contracts to waive some Medicare cost-sharing requirements
The AMA submitted recommendations on the future of the ACO program (AMA login required) to CMS in February. The agency is expected to issue a new proposed rule on Medicare ACOs soon.CMS releases additional materials for ICD-10 implementation
While the AMA continues to raise significant concerns with federal policymakers on behalf of physicians regarding implementation of the ICD-10 code set, the Centers for Medicare & Medicaid Services (CMS) is expected soon to publish a rule naming Oct. 1, 2015, as the new compliance deadline.
CMS continues to publish information about ICD-10 implementation, including the following item of which physicians should be aware:
- NCD changes: CMS already has made changes to 29 national coverage determinations (NCD) for ICD-10. The changes are outlined in a recent MLN Matters article.
- LCD changes: A list of local coverage determinations (LCD) converted to ICD-10 is available via CMS' LCDs by Contractor Index. Physicians can use the scroll box to select their Medicare Administrative Contractor (MAC) and select the "submit" button to view a list of states the specified MAC serves. Physicians then can select their MAC's name from the table to view the future translated LCDs.
- Specialty-specific webcast training: CMS has developed webcasts on ICD-10 documentation and coding concepts for cardiology, family medicine and internal medicine, orthopedics, obstetrics and gynecology, and pediatrics. Each webcast is free and lasts approximately 30 minutes. Webcasts are available to view at any time.
AMA testifies on ICD-10, virtual credit cards at NCVHS hearing
The AMA continued its strong advocacy on ICD-10 and virtual credit cards at a June 10 hearing of the National Committee on Vital and Health Statistics (NCVHS) Subcommittee on Standards. Stressing the high costs of ICD-10 implementation for physicians, the AMA recommended financial compensation for practices that meet the compliance deadline for the new code set.
The AMA also underscored the economic risks to physician practices during the code set transition, the lack of industry preparedness and the potential for implementation to disrupt quality measurement programs, such as meaningful use and the value-based payment modifier.
During another panel, the AMA outlined the issues surrounding health insurers' use of virtual credit cards to make claim payments to physicians. The AMA presented survey data that establishes the widespread scope of the problem and used a case study of a radiology practice to illustrate the significant loss of physician income associated with this payment method. Visit the NCVHS website to access participants' testimony, including the AMA's slides.
The AMA offers new physician educational resources about virtual credit cards and electronic funds transfer as well as a variety of resources about ICD-10.
Issue SpotlightPhysicians take on telemedicine to bolster care delivery
Recognizing the ability of telemedicine to improve access to care, increase care coordination and quality, and reduce growth in health care spending, the nation's physicians have set out to shape essential elements of telemedicine to ensure patients receive the best possible care.
At the 2014 AMA Annual Meeting earlier this month, physicians approved a set of principles for telemedicine set forth in a new report (AMA login required) by the AMA Council on Medical Service. Here are some of the top issues the AMA is addressing so the potential benefits of telemedicine can be harnessed for physicians and their patients:
Developing a solid evidence base. The new telemedicine principles call for additional research and the development of evidence-based clinical practice guidelines that should be followed when delivering telemedicine services. The AMA is working with medical specialty societies and is urging the Center for Medicare and Medicaid Innovation and the Patient Centered Outcomes Research Institute to significantly increase funding in this area.
Promoting the patient-physician relationship and care coordination. To ensure proper diagnoses and follow-up care, the principles specify that a valid patient-physician relationship should exist before using telemedicine or the physician should meet the standard of care and other safeguards outlined in the AMA policy for establishing this relationship using appropriate telecommunication technologies. (Even when physicians have an existing valid relationship, use of telemedicine should comply with the patient safeguards outlined in the policy.) Chief among the safeguards outlined in AMA policy is the need to ensure that these technologies are covered to enhance care coordination and information-sharing between those who provide virtual care and in-person care.
Ensuring physicians are able to practice in the patient's state. The AMA is working with the Federation of State Medical Boards and other stakeholders to advance an interstate compact that would streamline the licensing process, removing administrative and financial barriers to licensure in more than one state and facilitating the responsible practice of telemedicine across state lines. The principles call for physicians to be licensed where the patient receives the services and to follow that state's medical practice laws.
Identifying technical solutions and requirements. Telemedicine technology also must facilitate easy information sharing and comply with Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements. The AMA is working with telemedicine stakeholders to identify solutions and establish technical standards.
Enabling for appropriate reporting, payment and coverage. Medicaid programs in 46 states and the District of Columbia offer some form of payment for telemedicine services, but the definition and regulation of telemedicine varies considerably. Similarly, coverage by private insurers is quite different from one payer to another. The new telemedicine principles call for additional pilots that can demonstrate which kinds of payment and delivery models work best with this care. The AMA also is providing clear recommendations to policymakers and others about the conditions that should be met for telemedicine services to be covered and paid.
Providing education and tools for physicians. Educational resources can help physicians safely navigate this emerging field of care delivery, including such weighty concerns as HIPAA compliance and medical liability coverage. The AMA principles advise physicians to make sure their liability insurance covers telemedicine services—especially for patients in other states—before engaging in such activity.
The AMA also is advocating for adoption of these principles with state and federal lawmakers through testimony to congressional committees and other vital activities.
State UpdateFive steps to curbing prescription drug abuse
As governors from five major New England states last week met in Boston, AMA President Robert M. Wah, MD, published an editorial in the Boston Globe that urged lawmakers to focus on a five-pronged comprehensive public health approach that emphasizes treatment and prevention.
Dr. Wah highlighted the importance of pursuing these five steps:
- Maintain balance and state flexibility to guide policy decisions
- Ensure all major stakeholders are working together
- Place appropriate emphasis on prescription drug monitoring programs
- Recognize that substance abuse and addiction demands medical treatment
- Adopt appropriate patient privacy and confidentiality protections
One key element of treatment to help reduce deaths from opiate overdoses is availability and administration of naloxone, a proven opioid antagonist. At the 2014 AMA Annual Meeting in June, policy was adopted for the AMA to support and endorse "Good Samaritan" protections for callers or witnesses seeking medical help for overdose victims. Such policies would protect physicians, family members, friends and others who may otherwise be discouraged from aiding people who have overdosed.
Read more about the AMA's efforts to combat prescription drug abuse and diversion.
As part of the AMA's ongoing work to shape national policy concerning prescription drug abuse and diversion, AMA Board of Trustees Member Mary Anne McCaffree, MD, will represent the AMA at the National Conference of Insurance Legislators' (NCOIL) Summer Meeting July 10 in Boston.
A perinatal specialist, Dr. McCaffree will speak about neo-natal abstinence syndrome before a joint session of NCOIL's Health, LTC and Health Retirement Issues Committee and the Workers' Compensation Insurance Committee, which will consider proposed enhancements to NCOIL's "Best practices to address opioid abuse, misuse and diversion."
The AMA and several national medical specialty societies continue to work with NCOIL to help ensure a balanced public health approach to curbing prescription drug abuse and diversion. At the Boston meeting, lawmakers will discuss privacy and prescription drug monitoring programs, neonatal abstinence syndrome and drug take-back/safe disposal programs. The AMA also recently submitted recommendations (AMA login required) to NCOIL for ways the group can help tackle this public health crisis.
Judicial UpdateCourt: Physician not liable for patient's risky behavior
A decision this month by a state supreme court overturned a lower court ruling that discounted a patient's unsafe behavior from a medical liability determination.
In Kelly v. Haralampopoulos, two Colorado physicians were accused of medical liability when a patient experienced cardiac arrest during a procedure after presenting with abdominal pain. Testimony of close friends indicated that the patient had been recreationally using a dangerous drug that is known to cause cardiac arrest.
The trial court allowed this testimony to be considered in the jury's verdict, which was decided for the physician defendants. When the case moved to a court of appeals, however, the testimony was denied and the decision overturned.
The physicians appealed to the Colorado Supreme Court, which upheld the decision of the trial court, in a ruling upholding that patients can be at least partially responsible for their health outcomes as a result of their own unhealthy behavior.
The Litigation Center of the AMA and State Medical Societies supported the physicians in a friend-of-the-court brief. Read more about this case and similar ones in which the AMA Litigation Center has been involved.
Other NewsLast chance: Apply by July 1 to avoid meaningful use pay penalty
Physicians who wish to stave off next year's financial penalties for not meeting electronic health record (EHR) meaningful use requirements have until July 1 to apply for a hardship exemption. The AMA offers a new tip sheet (AMA login required) to help physicians avoid the 2015 penalty.
Even if physicians don't fit neatly into one of the six hardship categories, they should file for the vendor issues category, which may be broadly interpreted. It is called "Lack of control over the availability of Certified EHR Technology" on the application. In addition, physicians who are attempting to attest to meeting the meaningful use requirements but are concerned they won't be successful should file for a hardship exemption under the vendor software issues category as well. Read more about the hardship exemption categories at AMA Wire™.
The Centers for Medicare & Medicaid Services (CMS) recently released this year's list of approved Physician Quality Reporting System (PQRS) registries and Qualified Clinical Data Registries (QCDR).
Individual physicians and group practices who wish to report using the qualified registry method can review CMS' 2014 qualified registries list. Individual physicians who wish to report using the new QCDR method can review the agency's 2014 QCDR list. The QCDR reporting option is not available to group practices.
Some of the 2014 QCDRs are in the process of publishing their non-PQRS measures. For these QCDRs, "TBD" is displayed in the "non-PQRS measures information" column. The list will be updated and reposted once all of the non-PQRS measure publications are finalized. For more information about reporting using QCDRs and qualified registries, review the CMS documents "2014 PQRS: QCDR participation made simple" and "2014 registry reporting made simple."
Beginning July 1 the Centers for Medicare & Medicaid Services (CMS) will use updated Remittance Advice Remark Codes (RARC) for the Physician Quality Reporting System (PQRS), and the old codes will be deactivated at the same time.
Physicians who bill on a $0.00 Quality-Data Code line item will receive the N620 code, which will replace the current N365 code. Also, physicians who bill on a $0.01 Quality-Data Code line item will receive the CO 246 N572 code. The new RARC code N620 indicates that the PQRS codes were received into the CMS National Claims History database.
The new RARC N572 with the Claim Adjustment Reason Code 246 (with Group Code CO or PR) indicates that the procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted. Contact the QualityNet Help Desk at (866) 288-8912 or via email for additional information. The help desk is available from 8 a.m. to 8 p.m. Eastern time Monday through Friday. Visit the CMS PQRS Web page for additional information.
A new resource from the AMA Innovators Committee offers practical guidance for physicians interested in implementing new care delivery and payment models. "Where do I fit in? Dividing the pie in new payment models" (AMA login required) explains how physicians can ensure new delivery models translate into fair payments down to individual physicians and other health care professionals.
Physician innovators presenting their personal insights during a popular session at the 2014 AMA Annual Meeting pointed to this resource and other materials from the AMA Innovators Committee to give physicians the practical guidance they need. These resources include four guides on delivery and payment innovations and a series of archived webinars that offer up to nine AMA PRA Category 1 Credits™.