June 24, 2016 – MACRA: More Alphabet Soup

 

PRESIDENT’S MESSAGE Dr. Malcolm Reid

June 24,  2016 Volume 16, Number 23

Dear Colleagues:

The federal Government came up with MACRA in answer to the dissolution of the horrible SGR. While MSSNY, along with the AMA, was pooling our forces to override SGR fee cuts, other Medicare problems popped up. In an effort to address some of these problems, MACRA consolidated and revised Medicare’s Physician penalty and incentive programs, hoping to simplify and improve them. It appears that the result will be neither simplified nor improved.

What MACRA is supposed to do is alleviate the burdens of PQRS and MU.  Oh yes, we are still in alphabet soup. MACRA= Medicare Access and CHIP Reauthorization Act of 2015; PQRS= Physician Quality Reporting System; MU= Meaningful Use.

Now, under MACRA we now have MIPS and APMs.  MIPS=Merit-based Incentive Payment System and APMs= Alternative Payment Models.  MIPS allows Medicare clinicians to be paid for providing high value care through success in four performance categories: Quality, Advancing Care Information, Clinical Practice Improvement Activities, and Cost.

Clinicians who participate in APMs such as the new Comprehensive Primary Care Plus (CPC+) model, the Next Generation ACO model, and other Alternative Payment Models  would be exempt from MIPS reporting requirements and qualify for financial bonuses.  Under APMs, clinicians accept both risk and reward for providing coordinated, high-quality care.

For more information about MACRA, MIPS and APMs, please look at CMS’ website.

CMS’ PRESS release.

Oh yes, we are still in the soup –alphabet soup that is.

See article below regarding MSSNY’s comments on the CMS’ proposal.

Malcolm Reid, MD, MPP
MSSNY President

Please send your comments to comments@mssny.org

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MSSNY, Many Other Physician Organizations Comment on MACRA Implementation
Noting that the proposal by CMS to implement the MIPS and APM Medicare value-based payment programs are “far too complex for many physicians who are already drowning in required paperwork from public and private payers”, this week MSSNY submitted extensive comments to CMS to urge significant changes before the rule is finalized.  To read MSSNY’s comments, click here.  

In addition, MSSNY has signed on to a letter initiated by the American Medical Association with medical societies across the country, and is working with the Coalition of State Medical Societies on a joint letter.  These letters all stress to CMS the physician community’s strong concerns with the overwhelming complexity of this proposal, and the need to assure that physicians are exempted who have little possibility of earning more than it takes to comply.

With the comment deadline this Monday, June 27, physicians are encouraged to send their own comments to CMS by clicking here.

The comments were in response to the proposal announced by CMS in early May to implement the value-based payment programs contained in the MACRA legislation enacted by Congress in 2015 that repealed the Medicare SGR methodology.  While payment adjustments under the Merit Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) are not applied until 2019, it will be based upon care delivered to Medicare patients in 2017.  Under MIPS, Medicare payments could be adjusted up or down by 4% beginning in 2019, and up to +/ – 9% by 2022, with additional bonus payments possible.

The key points made by MSSNY and other associations in its comments included:

• The need to significantly raise the MIPS exemption threshold from 100 Medicare patients and $10,000 in Medicare revenue.
• The need to postpone the implementation start date to at least several months after January 1, 2017, and for a shorter “performance period”
• The need for a mechanism for physicians to receive comprehensive periodic feedback from CMS as to how they are performing in each of the 4 categories before a “performance period” ends
• The need to assure that the MIPS program for determining bonuses or penalties compares physicians practicing in similar specialties, and practice sizes rather than all being lumped into one big pool.
  (AUSTER)

Urge Governor Cuomo to Sign Step Therapy Override Bill
With the Legislature’s passage of a bill (A.2834-D/S.3419-C) last week to establish specific criteria for physicians to request an override of a health insurer step therapy medication protocol when it is in the best interest of their patients’ health, all physicians are urged to send a letter to Governor Cuomo to ask that he sign this important bill into law.  A letter can be sent here.

MSSNY strongly supported this bill, and worked with a wide array of patient advocacy organizations, specialty societies, hospitals, and pharmaceutical manufacturers to achieve passage of this legislation. We know the insurers are strongly fighting this bill, so the Governor’s office needs to hear your support.

This week, Long Island Newsday had an editorial in strong support of the bill.

The bill would require a health insurer to grant a physician’s override request of an insurer step therapy protocol if one of the following factors are present: 1) the drug required by the insurer is contraindicated or could likely cause an adverse reaction; 2) the drug required by the insurer is likely to be ineffective based upon the patient’s clinical history; 3) the patient has already tried the required medication, and it was not effective or caused an adverse reaction; 4) the patient is stable on the medication requested by the physician; 5) the medication is not in the best interests of the patient’s health.

While the legislation would generally require the health insurer to make its decision within 3 days of the override request of the physician, the insurer would be required to grant the override request within 24 hours of the request if the patient has a medical condition that places the health of such patient in serious jeopardy if they do not receive the requested medication.  Perhaps most importantly, if the physician’s request for an override is denied, it would enable a physician to formally appeal the decision both within the plan’s existing appeal mechanism as well as taking an external appeal.
(AUSTER, DEARS)                                                                                           

Governor Signs Opioid Package
In a three city whirlwind tour of the state, Governor Cuomo this week signed into law legislation designed to arrest the growing opioid epidemic. The effective date of each provision of law varies and is set forth below for your information. Importantly, the new seven day limit on the number of days for which opioids can be prescribed for the initial onset of acute pain will go into effect on July 22, 2016.

1. Mandate to complete three hours of CME training on pain management must be completed by July 1, 2017. Course standards and regulations are being developed. MSSNY in conjunction with OASAS and DOH, has already developed such a course—currently on its website. MSSNY will apply to assure that this course meets the standards developed by the agency.

2. Inpatient residential coverage without utilization review limitations becomes effective on January 1, 2017.

3. Requirements that DOH must create and pharmacies must make available information materials regarding the dangers of misuse and the potential for addiction to controlled substances to the public at the time of dispensing controlled substances will go into effect on October 22, 2016.

4. Requirements that hospitals must coordinate discharge planning for individuals with suspected substance use disorder with SUD programs go into effect on December 22, 2016.

5. Required use of utilization review tools designate by OASAS goes into effect on January 1, 2017.

6. Required access to a five day supply for emergency use of medication for substance use disorder and access to buprenorphine and naltrexone for detoxification without prior authorization goes into effect on January 1, 2017.

7. Involuntary commitment of a person incapacitated for drug or alcohol abuse for up to 72 hours goes into effect on September 22, 2016.

8. The new seven day limit on the number of days for which opioids can be prescribed for the initial onset of acute pain will go into effect on July 22, 2016.
   (DEARS, CLANCY, AUSTER) 

Physicians Urged To Send Letters of Support to Governor for ERX Changes
As reported in last week’s Capitol Update, two measures passed which will address issues which have arisen with the implementation of the e-prescribing mandate. Physicians are encouraged to send letters of support for each of these bills to the Governor to urge that he sign the bills into law.

The first bill, S. 6779, Hannon/A.9335-B, Gottfried would ease the onerous reporting burden on physicians every single time that they need to issue a paper prescription in lieu of e-prescribing.  The letter urging the Governor to sign the bill can be accessed by clicking on this link.

In March, the Bureau of Narcotics Enforcement announced that when a physician invokes one of the three statutory exceptions and writes/faxes or calls in a paper script because:  their technology or power has failed; the prescription will be filled outside of New York; or it would be impractical for the patient to obtain medications in a timely manner, they must electronically submit to the department an onerous amount of information about the issuance of the paper prescription. DOH asks that each time a paper/fax/oral prescription is issued, the prescriber must electronically inform the DOH of their name, address, phone number, email address, license number, patient’s initials and reason for the issuance of the paper prescription.

This creates an onerous burden for all physicians, particularly in situations where there is a protracted technological failure, and the physician needs to report dozens upon dozens of paper prescriptions. In fact, Surescripts has stated publicly that there is a 3-6% e-prescription transmission failure rate. This means that in the state of New York anywhere between 7.6 million to 15 million e-prescriptions will fail every year and each prescriber involved with these failures who subsequently write a paper prescription will need to file this information with the state.  In some small communities, even the patient’s initials can convey information that will enable others who access this information to identify the patient who will receive the medication.

The bill passed this week affords a much more preferable alternative by allowing physicians and other prescribers to make a notation in the patient’s chart indicating that they have invoked one of the three statutory exceptions.

The second bill A.10448, Schimel/S. 7537, Martins would authorize a pharmacy which does not have a particular medication in stock to transfer the prescription to another pharmacy. The letter urging the Governor to sign the bill can be accessed by clicking on the following link.

Currently, e-prescriptions cannot be transferred by one pharmacy to another thereby requiring the patient to return to or call the prescriber’s office to ask that he/she transmit the e-prescription to another pharmacy creating unnecessary burdens on the patient and delaying timely access to their medication.                                             (DEARS, AUSTER) 

HHS Announces Funding Opportunity to Assist Small Practices Prepare  for Value-Based Payment Programs
The U.S. Department of Health and Human Services announced this week an initiative to financially assist small practices preparing for Quality Payments under the Medicare Program.The $20 million funding will support “on-the-ground training and education” for physicians and other participating Medicare clinicians in both individual and small group practices of 15 clinicians or fewer – especially in historically under-resourced areas including rural and medically underserved areas.

“Doctors and healthcare providers in small and rural practices are critical to our goal of building a health care system that works for everyone,” said HHS Secretary Sylvia M. Burwell in a statement. “Supporting local health care providers with the resources and information necessary for them to provide quality care is a top priority for this administration.”

To read the HHS press release, click here.

The funding was allocated in the MACRA legislation passed by Congress in 2015 that repealed the SGR and established the MIPS and APM value-based payment programs (as replacements for the existing PQRS, meaningful use and VBM programs).   The press release notes that “organizations receiving the funding would support small practices by helping them think through what they need to be successful under the Quality Payment Program, such as what quality measures and/or electronic health record (EHR) may be appropriate for their practices’ needs. Organizations would also train clinicians about the new clinical practice improvement activities and how these new activities could fit into their practices’ workflow, or help practices evaluate their options for joining an Alternative Payment Model.”

HHS will announce the awardees by November.
(AUSTER)

Six Months Before You Re-Register License with NYS Department of Education, You Must Update Your Physician Profile
Physicians are required under New York State Public Health Law §2995-a and Education Law §6524, to update their Physician Profile in the six (6) months prior to the expiration of their current registration and submission of his/her biennial registration.  There has been recent email notification to physicians whose re-registration is due within the next six months from New York State Department of Health informing them that they must update their physician profile.  If a physician plans on renewing his/her registration with the State Department of Education, the Physician Profile must be updated.  If a physician is not renewing his/her registration no action is required.

To update the Profile please log on to the Health Commerce System (HCS) account here.

The Physician Profile icon is in the menu on the left of the screen.  If you need assistance in order to access your HCS account, please call 1-866-529-1890, Monday – Friday 8:00 am – 4:45 pm. If you need assistance or have questions specific to the Physician Profile, please call 1-888-338-6998, Monday – Friday 8:30 am – 4:45 pm.

If the profile is up to date, a physician must still log into the Physician Profile through his/her HCS account in order to confirm the information is current and accurate.

The Health Commerce System (HCS), accessible via the Internet, is the secure website for web-based interactions with the New York State Department of Health.  Besides being required to update a physician profile through the HCS, physicians need an HCS to order prescription pads; to check the Prescription Monitoring Program (PMP); tumor and cancer reporting and to access the Immunization Registry, etc.

Physicians who do not have a Health Commerce System account are urged to do so.  A paperless HCS account application can be found here.

Reported cases of Zika in New York City: 197

• 20 of the 197 cases were pregnant at the time of diagnosis;
• All cases contracted Zika while visiting other countries; and
• All patients have recovered.
• To date, 3,605 people in the city have been tested for the virus for a 5% infection rate. All of the confirmed cases of Zika in the city are from a result of traveling abroad. There have also been two cases of Guillain-Barré, a syndrome that has been associated with the virus, according to the CDC.
• The Zika statistics for New York City were reported in the Morbidity and Mortality Weekly Report as part of an effort to determine which demographic populations were getting tested. Officials from the city’s Department of Health and Mental Hygiene used Census data to cross-reference testing — rates with neighborhoods that have residents from regions at the center of the Zika crisis — Brazil, the Caribbean, Central America.

For More Information

• Zika virus specimen collection.
• Interim guidance for Zika virus testing of urine.

Medicare Trustees Report Shows Continued Slow Cost Growth
The Medicare Trustees projected that the trust fund financing Medicare’s hospital insurance coverage will remain fully funded until 2028, 11 years longer than they projected in 2009 before the passage of the Affordable Care Act.

Per-enrollee Medicare spending growth has been low, averaging 1.4 percent over the last five years, slower than GDP per capita (2.9 percent) and overall health expenditures per capita (3.4 percent). And over the next decade, per-enrollee Medicare spending growth (4.3 percent) is expected to continue to be lower than the growth in overall per capita national health expenditures (4.9 percent). Total Medicare spending is projected at a faster 6.9 percent average annual rate over the next decade, reflecting continued enrollment growth driven by the growth of the over-65 population.

The Medicare Trustees did highlight an area of spending growth, however, noting that that growth in the costs of prescription drugs paid by Medicare continue to exceed growth in other Medicare costs and overall health expenditures. Medicare Part D expenditures per enrollee are estimated to increase by an average of 5.8 percent annually through 2025, nearly 50 percent higher than the estimated increase in GDP per capita (3.9 percent) and higher than the combined per-enrollee growth rate for Medicare Part A and B (4.0 percent). The report found that these costs are trending higher than previously predicted, particularly for specialty drugs. A prior Department of Health and Human Services report also provided a detailed analysis of high cost prescription drug spending trends.

Based on early data showing the potential for a small Social Security cost of living adjustment, the Trustees Report projects that Medicare’s “hold harmless” protection will be triggered again this year. This would result in a small increase in Part B premiums for about 70 percent of Medicare beneficiaries, with increases in Part B costs spread over the remaining 30 percent, which includes individuals enrolling in Part B for the first time in 2017, those that do not receive a Social Security benefit or who are directly billed for their premium, Medicare and Medicaid dual-eligible beneficiaries, and current enrollees who pay an income related higher premium.

However, this a projection based on preliminary data. The final Social Security cost of living adjustment will be announced in the fall based on updated data. The 2017 Medicare Part B premiums, which typically differs from these projections, will be announced later in the year.

The report is available here.

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The 2016 MSI Survey Is Here!
CMS is once again conducting their annual survey of Medicare Administrative Contractors (MAC) performance and requesting feedback from the provider community NGS Medicare serves through the MAC Satisfaction Indicator (MSI). This survey should only take about 10 minutes of your time and helps NGS understand how they can better service you.

NGS Medicare encourages all Medicare Providers of service as well as their office staff members who work with National Government Services Medicare to participate in the survey!

1. What is the MAC Satisfaction Indicator (MSI)? The MSI is a tool used by CMS to measure provider satisfaction with their MAC. This survey is presented once a year and includes questions on services the MAC provides in these functional areas: Provider Outreach and Education, Provider Telephone Inquiries, Claims Processing, Electronic Data Interchange (EDI) Help Desk, Reopenings and Redeterminations (Appeals), Provider Enrollment, Medical Review, Self-Service Portal and Cost Report and Reimbursement.

1. Who is eligible to participate in the MSI? Medicare providers who receive services from their MAC can participate. This includes Medicare fee-for-service physicians, suppliers, health care practitioners and institutional facilities who serve Medicare beneficiaries across the country.

1. What does this mean to NGS? The MSI allows providers the opportunity to influence CMS’s understanding of Medicare contractor performance. In addition to monitoring NGS’s performance, CMS will use the results for monitoring trends, to improve oversight, and to increase efficiency of the Medicare program. CMS will incorporate the results into our MAC incentive plans. The MSI also provides NGS with more insight into our provider communities and it allows us to make process improvements based on this provider feedback.

To take the survey, click: here.

For Residents: Introducing NEJM Resident 360
NEJM Resident 360, a new website and discussion platform from NEJM Group, gives residents the information, resources, and support they need to approach each rotation with confidence. Create a profile now. Access to premium content is free with any NEJM Group individual or institutional subscription. 

Federal Panel Says Nasal Spray Flu Vaccine Should Not Be Used Next Flu Season
The AP (6/22, Stobbe) reports research presented at a medical meeting in Atlanta showed the nasal spray FluMist vaccine “was somewhat effective, but still not did not work as well as flu shots,” according to the maker of the vaccine, AstraZeneca. However, Centers for Disease Control and Prevention flu expert Dr. Joseph Bresee said, “We could find no evidence (the spray) was effective.” The nasal spray accounts for just 8 percent of the total flu vaccine doses produced each year. But because it’s mainly used in kids, about a third of the flu vaccinations of children were done with FluMist, health officials say.

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