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July 24, 2014

National Update

CMS proposes eliminating CME exclusion from Sunshine Act reporting

In the draft Medicare Physician Fee Schedule rule for 2015, the Centers for Medicare & Medicaid Services (CMS) proposed revoking the Physician Payments Sunshine Act exclusion from reporting of financial transfers manufacturers and group purchasing organizations make to organizations that offer continuing medical education (CME).

The change would apply to those offering independent CME accredited by the Accreditation Council for Continuing Medical Education or when credit is granted by the AMA, American Academy of Family Physicians, American Osteopathic Association or American Dental Association.

Under this proposal, the agency would exempt third-party transfers for CME only when an industry donor is unaware of the recipients or beneficiaries both before and after the funds are transferred. This policy revision raises concerns because the industry could learn the identities of speakers and participants after the funds have been transferred through brochures, programs and other publications related to a CME event.

The AMA is developing a Federation sign-on letter regarding challenges with the registration process for the Sunshine Act (also known as the Open Payments program) and the limited timeframe physicians have to review and potentially dispute their reports. Given the chilling impact the Medicare proposal could have on accredited CME, this issue will be added to that sign-on letter.

Important Sunshine Act reporting reminders: Companies, associations and foundations that employ physicians or have physicians on their governing boards will need to assess whether these individuals have transfers of value that are subject to reporting under the Sunshine Act. Physicians must register and file any disputes no later than Aug. 27 for items to be flagged as disputed in the initial public data release.

An online toolkit developed by the AMA provides practical information about navigating the Sunshine Act data release. Step-by-step instructions for registering in the Open Payments system also are posted at AMA Wire®:

The AMA also offers ready-made communications materials about this process so your organization can make sure your members are prepared.

Medicare awards 14 new quality improvement contracts

The Centers for Medicare & Medicaid Services (CMS) last week announced 14 new Quality Improvement Organization (QIO) contracts as part of its ongoing effort to restructure the QIO program. The new contractors, which will be known as the Quality Innovation Network (QIN)-QIOs, will work with physicians, other providers and communities on data-driven quality improvement initiatives.

According to a CMS news release, each QIN-QIO will work on strategic initiatives, such as:

QIN-QIOs also will provide technical assistance for improvements in the physician value-based modifier and other CMS value-based purchasing programs.

FDA proposes new health IT safety measures

Comments (AMA login required) filed July 7 by the AMA take a close look at a new report from the Food and Drug Administration (FDA) called the "FDA Safety and Innovation Act health IT report: Proposed risk-based regulatory framework." While federal efforts in this area are rather new, the AMA has been a vocal advocate for ensuring that health IT is deployed in a safe manner and that there are recourses for reporting safety events identified by physicians.

The report calls for establishing a risk-based framework along with FDA oversight of just the highest risk category the agency has termed "medical device health IT functions." In addition to the risk-based framework, the AMA supports the proposal to create a health IT safety center and has advocated for strong physician involvement in it.

Many questions remain, including how health IT that is not regulated by the FDA will be overseen from a safety perspective. The AMA will remain engaged in these policy discussions as they evolve and will advocate for a pathway for tracking and reporting all forms of health IT-related safety incidents.

Read more at AMA Wire in a recent post by AMA President Robert M. Wah, MD.

Meaningful use proposed rule still "all-or-nothing" approach

A proposed rule on the electronic health record (EHR) meaningful use program would make some important changes for physicians but still leaves the program's most pressing problem unaddressed. The AMA submitted comments (AMA login required) Monday.

The proposed rule would allow physicians to continue using the older version of certified EHR software (Version 2011), use a combination of new (Version 2014) and old, or use just the new version. The revision is intended to address concerns that many physicians did not receive updated software in a timely manner this year.

The proposal would apply only to physicians for whom the new software was not "fully functional" in 2014. Also of note, physicians who were scheduled to move to Stage 2 would be allowed to stay in Stage 1 for another year under this proposal.

The AMA generally supports these changes but is troubled that the proposed rule did not address the AMA's main concern with the meaningful use program: the "all-or-nothing" approach that requires physicians to meet 100 percent of the requirements to either obtain an incentive or avoid a penalty. The proposed rule also does not address quality measure reporting alignment issues with the Physician Quality Reporting System.

Finally, despite the AMA's requests to extend the meaningful use hardship deadline past July 1, the Centers for Medicare & Medicaid Services has elected not to do so. The AMA is aggressively seeking a number of significant changes to the overall program to make it much easier for physicians to comply and avoid financial penalties next year.

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Issue Spotlight

8 things you should know about Medicare's proposed payment rule

If the policies set forth in the 2015 Medicare Physician Fee Schedule proposed rule take effect, physicians will be in for a lot of changes—many of them unfavorable—next year. Here are the top eight things that should be on your radar:

1. A 21 percent payment cut is scheduled for April 1. The Centers for Medicare & Medicaid Services (CMS) observed in a fact sheet that current payment rates will apply through March as a result of the temporary payment patch enacted earlier this year and projected that payment rates will be cut by 20.9 percent April 1 unless Congress intervenes. The agency stated its support for repeal of the flawed sustainable growth rate formula that has triggered such large cuts.

2. Global surgical packages will be eliminated. The rule proposes to discontinue all 10-day global surgical packages by 2017 and 90-day packages the following year. Packages instead would include only preoperative care and care given the day of surgery. Consistent with longstanding AMA policy, the AMA plans to work with the affected medical specialty societies to protest this proposed change.

3. Payments will be adjusted by the Value-Based Payment Modifier beginning next year. Despite continued AMA opposition, CMS plans to levy steeper payment adjustments and to continue basing the adjustments on costs and quality data two years before the adjustment is applied. Physicians in groups of 100 or more will see payment penalties or bonuses next year, determined by their group's cost and quality performance in 2013. Bonuses and penalties based on 2014 performance will be applied to groups of 25-100 starting in 2016.

All physicians will be subject to the modifier beginning in 2017, at which point the potential penalty will double to 4 percent. The pool of money available for bonuses depends on how much is collected in penalties, so potential bonuses are not yet known.

4. Quality reporting requirements will be increased in the face of penalties. CMS has reiterated a 2 percent payment penalty for physicians who don't meet the 2015 Physician Quality Reporting System (PQRS) requirements and is proposing additional requirements physicians will need to fulfill. At the same time, the agency is proposing to cut the period physicians have to request an informal review of a PQRS penalty from 90 days to just 30 days.

5. PQRS data will be publicly reported. The rule proposes making all 2015 measure data from group practices available in 2016. The agency also is hoping it will be able to publish later that year individual measures for all physicians on Physician Compare, a website plagued by accuracy and usability problems since it launched in 2010.

6. Chronic care management services will be covered. Beginning next year, Medicare will pay $43.67 per patient per month for chronic care management provided by a physician's office and $32.58 for care provided by a facility. Such services involve non-face-to-face care coordination for patients with multiple serious chronic conditions that are expected to last at least 12 months or until death.

7. More telehealth services will be covered beginning in 2016. The proposed changes include greater access for patients in rural locations by expanding the number of rural sites.

8. A new timeline for changing physician codes and service values would take effect in 2016. This revised timeline will mean physicians can submit recommendations no later than Jan. 15 for the following year. The change not only will severely limit recommendations from the Relative Value Scale Update Committee (RUC) and CPT® Editorial Panel but also will increase the time for a new or revised code to be included in the Medicare fee schedule from 10-20 months to 20-27 months. The AMA already has suggested timeline revisions to CMS that would provide greater transparency and better alignment between relative value unit recommendations and the regulatory process.

Comments on the proposed rule are due Sept. 2. The AMA will circulate its draft comments to state and specialty medical associations in advance of the submission deadline.

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State Update

State lawmakers learn about importance of physician-led teams

In remarks delivered to members of the National Conference of Insurance Legislators' Health, Long-Term Care and Health Retirement Issues Committee during a meeting July 12, the AMA stressed the importance of physicians as leaders of multidisciplinary health care teams.

The AMA's remarks also highlighted new AMA policy on telemedicine (AMA login required) and encouraged these state lawmakers to support legislation that ensures proper payment for telemedicine services and protects the state-based system of medical licensure.

Physicians boost the economy in every state: Study

As states begin winding down legislative sessions, now can be a good opportunity to review the AMA's Economic Impact Study, which details the impact of private practicing physicians on state and national economies.

The report shows that, in addition to supporting the health of their communities, physicians play a vital role in the economy by supporting jobs, purchasing goods, and generating state and local tax revenue. This data may be useful as states begin considering their legislative priorities for next year.

The report's findings show physician impact nationally and in each state based on four key economic indicators: jobs, output, wages and benefits, and state and local tax revenues. Analysis is available for all privately practicing physicians as well as across 10 select specialties, including anesthesiology, cardiology, family medicine, general surgery, internal medicine, obstetrics and gynecology, orthopedic surgery, otolaryngology, pediatrics, and urology.

The AMA also has created supporting advocacy tools for state and national medical specialty societies, including a handout, backgrounder, ad and press release template about the study. View the national report and summaries of state-level data.

CDC issues call to put a stop to pill mills

The Centers for Disease Control and Prevention (CDC) recently issued a report that ranks states on several measures around prescribing and the use of prescription drugs. The report also calls for policy changes to put a stop to illegal pill mills.

The rankings include prescribing rates for opioid pain relievers, long-acting/extend-release pain relievers, high-dose opioid pain relievers and benzodiazepines. In response, AMA President Robert M. Wah, MD, emphasized the AMA's strong support to end pill mills and illegal prescribing practices.

The focus, however, "must include a strong emphasis on increasing access to substance abuse treatment and prevention efforts across the nation," Dr. Wah said. The AMA hopes "this new data will help provide states and public health authorities with important information that can be used to reduce the crisis of prescription drug abuse, diversion, overdose and death."

At the same time, the AMA noted that state rankings are only one small piece of the information policymakers and public health officials need. That is why the association continues to support comprehensive solutions and work with the federal government and national organizations to advance such an approach.

Additional information is available on the AMA's "Combating prescription drug abuse and diversion" Web page.

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Judicial Update

Court considers: Can doctors sue insurers for underpaid claims?

At stake in a case before an appeals court is physicians' right to bring a lawsuit against an insurer that fails to pay correctly for medically necessary services provided to a covered patient. Physicians are weighing in as the court considers whether a previous ruling that bars such action should stand.

In North Jersey Brain and Spine Center v. Aetna, a physician practice that received assignments of benefits from patients with employer-sponsored health plans sued the insurer for denying and underpaying medically necessary surgeries for three different patients. The claims were brought to court only after the practice exhausted internal appeals processes with the insurer.

The district court in which the case originally was heard ruled that physicians must have more than the standard assignment of benefits to give them grounds for a lawsuit. The decision goes against decades of previous court rulings, accepted practice and the intention of the Employee Retirement Income Security Act (ERISA). The case now is being heard by a U.S. court of appeals in Philadelphia.

Read more at AMA Wire to learn more about this case and how the Litigation Center of the AMA and State Medical Societies and the Medical Society of New Jersey are involved.

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Other News

CMS clarifies EHR incentive program calculations

A new frequently asked question posted by the Centers for Medicare & Medicaid Services (CMS) provides clarification about reporting for the electronic health record (EHR) meaningful use program. Physicians should talk to their vendors to ensure their certified EHR is not calculating numerator data outside of the EHR reporting period (90 days for 2014).

The numerator for the following meaningful use measures should include only actions that take place within the EHR reporting period: preventive care (patient reminders) and secure electronic messaging.

For all other meaningful use measures, the actions may reasonably fall outside the EHR reporting period timeframe but must take place no earlier than the start of the reporting year and no later than the date of attestation so the patients can be counted in the numerator. (The exception would be when a longer look-back period is specifically indicated for the objective or measure). CMS issued this clarification because many vendors gathering data before the start of the EHR reporting period.

New resource explains how health care reforms really work

A new resource (AMA login required) from the AMA Innovators Committee provides guidance to practicing physicians on how to ensure that new delivery models translate into fair payments down to individual physicians and other health care professionals. This resource caps off a four-part series of resources on delivery and payment innovations developed by the AMA Innovators Committee.

In addition, physicians can earn up to nine AMA PRA Category 1 Credits™ by participating in on-demand access to a series of webinars on delivery and payment reform.

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News You Can Use

Following is suggested content to use in your association's communication vehicles beginning in July. This month's focus is on the Physician Payments Sunshine Act, for which physicians need to start preparing now. Ready-made communications materials—including articles, social media posts and an infographic—are available online.

Please email Terri Marchiori of the AMA to let us know which materials you're placing, your distribution channels, the response from your members and any other metrics, such as audience reach.

Sunshine Act article on step 1 of registration and review process (AMA login required)

Sunshine Act article on step 2 of registration and review process (AMA login required)

Sunshine Act article on step 3 of registration and review process (AMA login required)

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Upcoming Events

July 28:
Grassroots webinar on repealing Medicare's sustainable growth rate (SGR) formula with Rep. Ami Bera, MD, D-California, at 7:30 p.m. Eastern time. Register now.

Feb. 20-22:
AMPAC Candidate Workshop in Arlington, Virginia. Apply today.

April 15-19:
AMPAC Campaign School in Arlington, Virginia. Apply today.

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