Jan. 12, 2017: National Advocacy Update

The AMA welcomes legislative proposals that make insurance coverage "more affordable, provide greater choice and increase the number of those insured," AMA Executive Vice President and CEO James L. Madara, MD, said in a Jan. 3 letter to House and Senate leadership.

But policy makers ought to provide "reasonable detail" about their replacement plan before moving to alter coverage provided under the Affordable Care Act, Dr. Madara wrote. "Patients and other stakeholders should be able to clearly compare current policy to new proposals so they can make informed decisions about whether it represents a step forward in the ongoing process of health reform."

As policy makers consider systemic reforms designed to make insurance coverage more affordable and accessible, he added, "it is essential that gains in the number of Americans with health insurance coverage be maintained."

The letter to Capitol Hill leaders comes as Congress prepares to repeal portions of the ACA through the budget reconciliation process. The AMA supported passage of the ACA "because it was a significant improvement on the status quo at the time," Dr. Madara wrote, adding that "we continue to embrace the primary goal of that law—to make high quality, affordable health care coverage accessible to all Americans."

Yet, Dr. Madara added, President Obama's signature legislative achievement "is imperfect and there are a number of issues that need to be addressed." The AMA looks forward to engaging lawmakers on proposals that are consistent with the Association's vision for health care reform. That vision arises out of a comprehensive policy framework refined over two decades through the AMA House of Delegates, which is composed of representatives of more than 190 state and national specialty medical societies.

The AMA, Dr. Madara wrote, is ready to work with lawmakers to continue the "ongoing quest for improvement" that health system reform represents. Such work, he wrote, is intended to meet the goal of "ensuring that all Americans have access to high quality, affordable health coverage."

The Senate passed the Fiscal Year 2017 Budget Resolution (S. Con. Res. 3) with plans to hold a vote by the end of the week. The House of Representatives is expected to take up and pass the measure shortly afterward, though House leadership is still working to secure the votes needed for passage. The Budget Resolution generally establishes Congressional spending levels for a given year or years, and also serves as a messaging tool for policy priorities. It cannot be used to make actual policy changes.

The resolution currently under consideration is for the 2017 Fiscal Year, which actually started on October 1, 2016. The primary purpose for adopting a budget at this late date is triggering the reconciliation process. Reconciliation provides for expedited procedures in the Senate that will allow for repeal of key portions of the Affordable Care Act (ACA) with only a simple majority.

If the resolution is adopted, House and Senate committees will work on legislation targeting critical spending and revenue provisions of the ACA. However, the path to ultimate consideration of the reconciliation bill and any possible legislation to provide new health coverage options is still uncertain.

The House of Representatives Jan. 9 passed four AMA-supported public health bills that would better coordinate care and clarify existing law. All of the bills previously passed the House by voice vote in the 114th Congress. The bills include:

• The "Sports Medicine Licensure Clarity Act of 2016" (H.R. 302), sponsored by Rep. Brett Guthrie, R-Ky., would ensure that sports medicine professionals are covered by their medical liability insurance when providing care to athletes or teams in other states. The bill passed by voice vote.
• The "National Clinical Care Commission Act" (H.R. 309), sponsored by Rep. Pete Olsen, R-Texas, would establish a National Clinical Care Commission to evaluate and recommend solutions to better coordinate and use federal programs to provide care for patients with metabolic syndromes and related autoimmune disorders. The bill passed by voice vote.
• The "Protecting Patient Access to Emergency Medications Act" (H.R. 304), sponsored by Rep. Richard Hudson, R-N.C., would improve the Drug Enforcement Administration registration process for emergency medical services (EMS) agencies and clarify that EMS professionals are permitted to administer controlled substances pursuant to standing or verbal orders when certain conditions are met. The bill passed by a vote of 404-0.
• The "Improving Access to Maternity Care Act" (H.R. 315), sponsored by Rep. Michael Burgess, MD, R-Texas, would increase data collection by the Department of Health and Human Services to place maternal health professionals in more appropriate geographic regions through their participation in the National Health Service Corps. The House passed the bill by a vote of 405-0.

If a physician or practice plans to participate in the 2017 Quality Payment Program (QPP), also known as the Merit-based Incentive Payment System (MIPS), with the goal of receiving a bonus in 2019, it is highly recommended that they review the recently released 2017 QPP measure benchmark information. The quality benchmark information does not apply to physicians who plan on minimal participation in 2017 only to avoid a 2019 penalty—submit one measure, one time in 2017.

The 2017 QPP benchmark information was released late last week and posted to the Centers for Medicare and Medicaid Services (CMS) QPP website. The benchmark calculations for the 2017 performance year use data submitted for the Physician Quality Reporting System (PQRS) in 2015 by QPP provider types who were eligible for MIPS but not newly enrolled that year, or by groups with at least one such clinician. When a clinician submits measures for the QPP Quality Performance Category, each measure is assessed against its benchmarks to determine how many points will be earned. A clinician can receive anywhere from three to 10 points for each measure, not including any bonus points.

Benchmarks are specific to the type of submission mechanism: EHRs, QCDRs/Registries, CAHPS and claims. For CG-CAHPS, the benchmarks are based on two sets of data: 2015 PQRS CAHPS and 2015 ACO CAHPS data. Submissions via the CMS Web Interface will use benchmarks from the Shared Savings Programs.

Each benchmark is presented in terms of deciles. Points will be awarded within each decile (see Table 1). Clinicians who receive a score in the first or second decile will receive three points. Clinicians who are in the third decile will receive somewhere between three and 3.9 points depending on their exact position in the decile, and clinicians in higher deciles will receive a corresponding number of points. For example, if a clinician submits data showing 83 percent on the measure, and the fifth decile begins at 72 percent and the sixth decile begins at 85 percent, then the clinician will receive between five and 5.9 points. For measures where a positive performance is seen in a lower score, the scores are reversed in the benchmark deciles.

The Centers for Medicare and Medicaid Services (CMS) last week released and posted to the Quality Payment Program (QPP) website the list of patient-facing encounter codes. The list is used to determine the non-patient facing status of clinicians eligible for the Merit-based Incentive Payment System (MIPS). Given the flexibility in program requirements for non-patient facing clinicians, the encounter codes are critical for CMS to identify MIPS-eligible clinicians.

A non-patient facing MIPS-eligible clinician is:

• An individual MIPS-eligible clinician who bills 100 or fewer patient-facing encounters, including Medicare telehealth services defined in section 1834(m) of the Act, during the non-patient facing determination period; and
• A group in which more than 75 percent of clinicians billing under the group's TIN meet the definition of a non-patient facing MIPS-eligible clinician during the determination period

The list of patient-facing encounter codes are categorized into three overarching groups of codes—Evaluation and Management Codes, Surgical and Procedural Codes and Visit Codes. The use of these codes classifies MIPS-eligible clinicians as non-patient facing and patient-facing.

As an AMA notice reminded physicians in July, balance billing of Medicare patients enrolled in the Qualified Medicare Beneficiary (QMB) program is prohibited. The QMB program is a Medicaid program that helps very low-income patients who are enrolled in both Medicare and Medicaid with their Medicare cost-sharing.

In response to physician concerns that it can be difficult to identify their QMB patients, the Centers for Medicare and Medicaid Services (CMS) Acting Administrator Andy Slavitt recently notified the AMA of new steps the agency is taking to inform physicians of patients' QMB status:

• If a QMB patient contacts CMS about persistent inappropriate billing, the Medicare Administrative Contractor will send a letter to the provider identifying the patient's QMB status and associated billing policies
• CMS is modifying its billing systems so that it will be able to notify physicians through the Standard Provider Remittance Advice if their patients are enrolled in the QMB program
• CMS is exploring options for improving its eligibility query system to inform physicians of patients' QMB enrollment before claims are submitted

Additional information is available from the Medicare Learning Network (PDF).

• Jan. 12, 2017: Advocacy spotlight on The top issues that will affect physicians in 2017  
• Jan. 12, 2017: State Advocacy Update 
• Jan. 12, 2017: Judicial Advocacy Update