MSSNYeNews: August 9, 2019 – House of Medicine Divided Cannot Stand

PRESIDENT’S MESSAGE Arthur Fougner, MD MSSNY President MSSNY eNews August 9, 2019 Vol. 22  Number 30

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Colleagues:

“We must indeed all hang together, or most assuredly, we shall all hang separately.”
Benjamin Franklin

This week, famed physician-author Dr. Eric Topol generated quite a buzz with a piece in The New Yorker entitled “Why Doctors Should Organize.” Beginning with the recent #ThisIsOurLane pushback against a snarky NRA piece, Dr. Topol outlines past history of successes achieved when doctors organized. He rightly notes the rise of physician burnout engendered in no small part by electronic medical records which reduce caring professionals to data-entry clerks. The severing of the patient-physician relationship is also noted, thanks to the efforts of Regulators and Managed Care. Physicians, if organized, could be a powerful force but “the profession is balkanized.”

Where Dr. Topol and I part company is his assertion that Medical Societies should not be concerned with “protecting the interests of doctors.” While he is correct in recommending that a medical organization should promote the interests of the public, he’s somehow missed the history of, for example, the AMA post-Sunbeam. Eric, Medical Societies can and should do both. I’ll simply say that if physicians don’t stand up for ourselves and represent, who will?

So Dr. Topol, I am happy to continue this dialogue because you have clearly diagnosed the illness and the cure IS organizing. We must tear down the silos. We agree more than we disagree and I feel we can all work together for the good of our noble profession. We must. Our patients are counting on it.

Or, as Billy Joel put it, we will all go down together.

Arthur Fougner, MD
MSSNY President 

Comments? comments@mssny.org; @mssnytweet; @sonodoc99

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Physicians Must Make Their Voices Heard on Surprise Billing Proposals
Discussions are still ongoing regarding a national solution to surprise bills and the current incarnation winding its way through Congress would use a disastrous benchmarking system that would leave all of the power in insurers’ hands. Legislation such as S1895 and HR3630 would allow insurers to create an artificial ceiling for payment, giving market dominant insurers new incentives to drop physicians from their networks (as they have in California) and potentially limiting patient access to needed specialty care in in hospital emergency departments.

Given these threats, please take the time to send a letter to your members of Congress by going here. The letter is pre-populated and allows you to get the message to the right individuals in just a few short minutes.  Please also work with your local county medical society to arrange to meet with your Representative of Congress, as legislators are now home in their districts until the end of September.  To find your representative, go here, where you can find their contact information including phone number and Twitter handle. Please speak with their staffs and if possible, request a meeting to discuss the issue in more detail.

For more information about why this legislation is worrisome, check out the following articles. Congress is About to Give Health Insurance Companies the Nuclear Weapon discusses how it would control surprise billing mediation for any patient in an ERISA-regulated health plan and why that would likely lead to a massive cut in physician compensation. Congress, Don’t Harm Patients With The Wrong Surprise Medical Bills Solution also provides a strong overview of the topic.

MSSNY supports an approach such as HR 3502 (Ruiz-Roe-Morelle) that is modeled after New York’s acclaimed law which has shown to be remarkably effective and fair.   It mandates use of an independent dispute resolution system similar to New York’s instead of utilizing an insurer-determined benchmark.

Please do not let Congress give insurers even more ability to implement abusive tactics that interfere with needed patient care.

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Five Measles Cases Reported in Mennonite Community in Wyoming County
Health officials say they’ve confirmed five cases of measles in a Mennonite community in western New York. The DOH says Thursday the cases were recorded in Wyoming County. The department has issued an advisory to notify regional health care providers of the potential for exposure.

Amid the nation’s worst measles outbreak in decades, Gov. Cuomo in June signed a law ending all non-medical exemptions for vaccines required for children to attend school in the state. The CDC Control has counted nearly 1,200 cases of measles in 30 states so far this year. About three-quarters of the cases are linked to outbreaks in New York.

FDA Investigating 127 Cases of Seizures After Vaping
The Food and Drug Administration is investigating 127 cases of people suffering from seizures after vaping, the agency announced Wednesday.

The agency received about 92 new reports of people, especially kids and young adults, experiencing seizures after using e-cigarettes since it first announced its investigation into the issue in April. The FDA said it’s unclear whether e-cigarettes caused the seizures and cautioned these cases occurred over a 10-year period.

When the FDA announced its investigation in the spring, it asked for people to let the agency know if they had ever experienced this. The FDA on Wednesday again encouraged people to report if they had seizures after vaping.

“We appreciate the public response to our initial call for reports, and we strongly encourage the public to submit new or follow-up reports with as much detail as possible,” acting FDA Commissioner Ned Sharpless said in a statement.

“Additional reports or more detailed information about these incidents are vital to help inform our analysis and may help us identify common risk factors and determine whether any specific e-cigarette product attributes, such as nicotine content or formulation, may be more likely to contribute to seizures,” he added.

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Veterans’ Care Claims Inappropriately Denied
Veteran Affairs (VA) claims processors inappropriately processed claims for emergency care received at non-VA hospitals, resulting in denied or rejected claims for tens of thousands of veterans, according to a VA Office of Inspector General (OIG) report released this week. VA’s OIG noted that denied or rejected claims can leave veterans on the hook for the total costs of their care.

Play Ball! Baseball Players May Live Longer than Other Pros and American Men
Professional baseball players may live longer than other professional athletes or American men overall, study indicates the New York Times (8/7) reports on a study published in JAMA Internal Medicine, in which researchers found that professional baseball players may have greater life expectancy than other professional athletes “and American men in general.”

The researchers also found that professional baseball players with long careers are less likely to die from cardiovascular disease and certain other diseases, but more likely to die from cancer, especially lung and skin cancer.

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New Apps Give Updates to Waiting Family Members During Surgery
The Wall Street Journal (8/6) reports that startups and large healthcare companies are developing tools designed to give family members updates on the status of their relatives during surgery or hospital stays.

USPSTF Recommends Against Pancreatic Cancer Screening
Reaffirming its 2004 statement, the U.S. Preventive Services Task Force (USPSTF) has issued a ‘D’ recommendation against screening for pancreatic cancer in low-risk adults with no signs or symptoms of this lethal disease.” The USPSTF authors wrote in their recommendation statement  published online in JAMA that “the USPSTF found no new substantial evidence that would change its recommendation and therefore reaffirms its recommendation against screening for pancreatic cancer in asymptomatic adults.”

The task force “concluded that screening has the potential for significant harm owing to the low prevalence of pancreatic cancer (12.9 cases per 100,00 person-years), the poor outcomes of treatment (5-year survival rate of only 9.3%), the limited accuracy of screening tests, and the invasive nature of diagnostic tests.”

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Review Suggests Chronic Hepatitis Can Be Eliminated Globally
MedPage Today reports that “chronic hepatitis is a major public health challenge that can be eliminated globally, according to an infectious disease expert” who conducted a review study. The review study found that “although progress has been made in the prevention and treatment of chronic hepatitis C virus (HCV) and hepatitis B virus (HBV) infections, challenges remain.”

The author suggests one step to achieving elimination of hepatitis is that, “all patients with risk factors should be tested for HCV and HBV and all persons born between 1945 and 1965 should be routinely tested for HCV to prevent liver disease and hepatitis transmission.” Moreover, the researcher “advised that ‘all who are positive for HBsAg or HCV should be evaluated for treatment and those susceptible to HBV or HAV should be vaccinated.’” The findings were published in the New England Journal of Medicine. https://bit.ly/2OMkY8h

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CMS Releases Proposed 2020 Medicare Rule; Significant Up & Down Specialty Impacts
CMS recently released a 1700-page proposed rule for the 2020 Medicare physician fee schedule (PFS). CMS notes that “with the budget neutrality adjustment to account for changes in RVUs, as required by law, the proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

On a positive note, the 3-year review of Medicare GPCIs would produce a slight upward adjustment to the Geographic Adjustment Factors for the 5 New York Medicare payment localities.

However, it should be noted that the proposed changes to Medicare payment proposed in this rule could produce some significant upward and downward adjustments to Medicare physician payment, based upon specialty, if CMS finalizes the proposal without modification. Please see Table 111 on pp.1187-1188 of the proposed rule for a possible specialty by specialty impact.

For example, it predicts an overall +16% increase for Endocrinology, +15% for Rheumatology, +12% for Family Practice and Hematology/Oncology, +8% for Urology and Neurology, and +7% for Ob-GYN and Allergy/Immunology.  On the other hand, it predicts an overall -10% decrease for ophthalmology, -8% for Radiology and Cardiac Surgery, and -7% for Anesthesiology, Emergency Medicine and Thoracic Surgery.  The AMA notes that this impact table “should be viewed with caution” as they believe it may contain some errors.

For more information from CMS on the proposed rule, click here.  For a comprehensive AMA summary of the proposed rule, click here.

The AMA provided state medical societies with an overview of 2 of the key components of this rule:

Changes to E&M Coding and the MIPS Program

• Office Visits – Evaluation and Management – While retaining the important modifications to reduce documentation burden, CMS will implement coding and payment modifications in 2021 that are based on the resources required to perform various levels of office visits. This will ensure that physicians treating the sickest patients are not unfairly penalized, while providing simpler solutions to coding and documentation.

Following CMS’ proposal last year to collapse payment for office visits, the AMA coordinated a response from 170 national medical specialty societies and state medical associations urging a different solution. The CPT Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC) convened a Workgroup, that adopted changes in February 2019, to document office visits on either medical decision making or time spent on the date of the encounter.  According to AMA, CMS accepted most of the CPT framework and RUC recommendations.  Among the key aspects of the Office Visit Proposed Rule:

• Effective January 1, 2021, CMS will adopt the CPT guidelines to report office visits based on either medical decision making or physician time.
• CMS adopted the RUC work recommendations for the office visit codes. The work value increases represent $3 billion in redistributed spending, resulting in a 3% reduction in the conversion factor.
• CMS adopted the RUC physician time recommendations. Coupled with the work value increases and some modifications in direct practice costs, these changes lead to an additional $2 billion in redistributed spending, resulting in an additional 2% across-the-board reduction.
• Two departures from the CPT and RUC recommendations that we will need to be addressed:

• • CMS would implement an add-on payment for office visits for primary care and patients with serious or complex conditions. This proposal redistributes an additional $2 billion, resulting in an additional 2% reduction to the Medicare conversion factor.
  • Although the surgical specialties participated in the RUC survey and their data and vignettes were incorporated into the RUC recommendations, CMS proposes not to apply the office visit increases to the global surgery packages.

• Merit-based Incentive Payment System (MIPS) – The AMA noted that it is encouraged by results showing 95% of eligible clinicians successfully participated in MIPS in 2017, increasing to 98% in 2018 based on initial results. However, many physicians report that the current program is too costly and requires reporting for reporting’s sake, diverting time from patient care.

The AMA noted that, in the 2020 proposed rule, CMS embraced the AMA’s proposed concept for streamlining MIPS. The agency outlined a high-level framework and seeks feedback on an episode-based approach to MIPS, which it is calling the MIPS Value Pathways (MVP). The attached MVP diagram is included in the rule.

In the AMA’s view, an MVP-type approach could be a turning point for the program because an option that ties MIPS to episodes of care has the potential to be more clinically relevant, less burdensome, and a stepping stone to alternative payment models.  The AMA does have concerns with several specific aspects of MVP that CMS has proposed, such as a return to the use of controversial population health administrative claims measures that the AMA successfully fought to eliminate from the initial MIPS program.  CMS does not plan initial implementation of an MVP approach until 2021.