November 30, 2018 – Single Payor Update!
Thomas J. Madejski, MD
November 30, 2018
Volume 21 Number 43
The MSSNY Enews staff had some well-deserved rest during the Thanksgiving holiday. During the holiday, I spent some time with family and friends and many of my patients. I also spent some time on MSSNY business and reflected on all I have to be thankful for.
I’m thankful for each and every one of our members. Your support of MSSNY allows us to continue to advance the interests of our patients, the public health of the citizens of New York State, the best practice of medicine, and stewardship of our profession. I’m thankful for each of our MSSNY Committee members, and especially my Committee Chairs. Their devotion to creating and crafting policy to improve care, and to promote the art of science and medicine, is critical to the lifespan and health span of our fellow New Yorkers.
Thanks to the MSSNY Council members. We truly are in a new Golden Age of medicine. Your help in prioritization and refinement of the many activities that occur under the MSSNY umbrella is invaluable to me as we work to continue to expand our reach and impact on behalf of our patients. I’m especially thankful for the thoughts and efforts of my colleagues in the Office of the President, Dr. Bonnie Litvack, Dr. Arthur Fougner, and Dr. Charles Rothberg. They provide constant feedback and assistance to me as we represent MSSNY across the state and throughout the nation.
Finally, I’m most thankful for the MSSNY staff. Mr. Phil Schuh, our MSSNY Executive Vice President, leads a talented and devoted team that supports and enhances our efforts on behalf of our members.
I hope that each of you were able to spend time with your families and have had some time to recharge your batteries for the important work you do for the people of New York.
I also had some time to catch up on some reading and recommend to you an article in Health Affairs which discusses how “to fix” primary care.
I’ve been practicing geriatric medicine for a number of years. Experts have been trying to fix primary care from the time I entered medical school. The solutions proposed haven’t changed much. However, we are always on the lookout for new solutions in this changing climate for physicians.
Please share your suggestions or thoughts with me at firstname.lastname@example.org.
Thomas J. Madejski, MD
Single Payor Legislation Update
With Democrats now in control of both Houses of the State Legislature, it significantly enhances the possibility of the enactment of the New York Health Act (NYHA), legislation to establish a single payer system. NYHA would provide universal insurance coverage without copays, deductibles or premiums for all New Yorkers. It would also prohibit health insurance companies from offering similar coverage.
According to the recent RAND study it would require $139 billion in new tax revenue (a 156% increase) by 2022. The bill has passed the Assembly several times in recent years but was never voted on in the previously Republican controlled Senate. Its current incarnation is sparse – just 23 pages of text – and does not include significant details sought by many stakeholders regarding how such an enormous proposal would be implemented.
Earlier this fall, MSSNY and New York County Medical Society leadership met with Assembly Health Committee Chair Richard Gottfried (and NYHA bill sponsor) to discuss questions expressed by physicians both in opposition and in support of the NYHA bill, including:
- How burdensome will prior authorization requirements be?
- What will be the process for patients to appeal when recommended care has been denied?
- How meaningful will be the right for physicians to collectively negotiate with a NYHA Board?
- Could state budget limitations result in a grossly inadequate Medicaid-type payment structure that would make it impossible for many physicians to remain in practice in New York?
- Should liability reform be included given the enormous medical costs arising from “defensive medicine”?
In recent days leaders in New York state government have tempered expectations following the election. Incoming Senate Majority Leader Andrea Stewart-Cousins stated this week that “It’s a conversation we have yet to have in the Senate…I can certainly commit to having it heard.” Governor Cuomo has stated “Conceptually I think it’s the right way to go in. I believe it’s more feasible financially on the national level. No state has been able to finance the transition costs.” Democratic Senator Elect Alessandra Biaggi, a strong supporter of the single payer concept stated “…that’s going to mean taking some time to be thoughtful about how we’re going to pay for it.” Bill Hammond, noted health policy expert and the Empire Center’s Director of Health Policy, has repeatedly voiced concerns over the many possible negative consequences of the proposal.
Senator Gustavo Rivera, who is widely expected to take over as Chair of the Senate Health Committee in 2019, stated this week that he and Assemblyman Gottfried would soon be releasing a new version of the New York Health Act to address concerns from “stakeholders”. He did acknowledge that it is an “incredibly complicated piece of legislation”, admitting that change would be gradual and would not take place overnight, stating “If it were to pass today, it would still take two to three years to put all the regulations together that would be necessary to make the transition.”
The NYHA seemingly has a path forward this year with Democrats controlling state government, but it remains to be seen if all sides will align, configuring the details necessary to make the system actually work and gathering enough support to bring it to fruition. One “wild card” is the fact that there will be 14 new Democratic State Senators in Albany in 2019. With the consideration of this issue so fluid, please remain alert for further updates.
NY Comptroller Tom DiNapoli Discrepancies Show I-STOP Needs to Be Better
A new audit has found about a third of New Yorkers on Medicaid being treated for opioid addiction received a prescription for narcotic painkillers over a four-year period — highlighting a potential problem nationwide with drug monitoring systems. The New York comptroller’s audit this week said of those addicts who found a doctor to prescribe them opioids between Oct. 1, 2013, and Sept. 30, 2017, 3 percent — or nearly 19,000 people –sought medical care for an overdose within a month of filling those prescriptions. Twelve died.
The audit found that treatment programs did not always check the state’s Internet System for Tracking Over-Prescribing (I-STOP) database. The study found a sample of 25 patients from three treatment programs received more than 1,000 Medicaid opioid prescriptions while in treatment for abuse over the four-year period. New York law requires treatment programs to check the I-STOP database every time a medication-assisted opioid was prescribed for take-home use.
DiNapoli recommended that the DOH develop a method for notifying treatment programs when the database shows Medicaid recipients receive potentially dangerous prescriptions. His office also suggested the programs upload their own patient info when accessing the database, and that the DOH conduct risk assessments for individuals receiving medication-assisted treatment.
NY DFS Approves CVS-Aetna with Several Conditions
The New York State Department of Financial Services (DFS) announced their final approval of the massive proposed acquisition of Aetna by CVS, albeit with numerous conditions, paving the way for the consolidation of two of the nation’s largest healthcare companies. New York was one of the last states to approve the transaction after it was approved by the US Department of Justice and several other states.
The full list of conditions, designed to ensure fair business practices by the merged entity, can be found here. The conditions include:
- Prohibiting use of funds from any Aetna company or affiliate covering New Yorkers to pay for its acquisition;
- Prohibiting costs derived from the acquisition, including executive compensation, from being passed on to any domestic or foreign Aetna New York insurer;
- Prohibiting increased health insurance rates to pay for the cost of the acquisition;
- Prohibiting dividends to be paid by Aetna without the express prior approval of DFS for 3 years;
- Prohibiting preferential PBM pricing to any Aetna-affiliated health insurer licensed in New York, to better ensure insurance competitors can continue to fairly purchase PBM services from Caremark;
- Limiting changes to Aetna’s healthcare provider networks for 3 years, including maintaining access to non-chain New York pharmacies;
- Contributing $40 million to New York State, to support health insurance education and enrollment activities and strengthen New York health care transformation activities, which may include payments to the New York State Health Care Transformation Fund
- Requiring an independent third-party audit to assess whether Aetna employees have accessed Confidential Information in violation of firewall policies.
Moreover, the DFS press release noted that “CVS committed at the DFS public hearing in October and as part of the approval process that CVS Health and its subsidiaries will take no action to oppose” legislation requiring a New York license for PBMs to operate.
While the conditional approval agreement addresses to some degree some of the concerns raised by MSSNY over the last year, physicians remain very concerned about the adverse impact to the health care delivery system in New York given the enormous reach of this transaction. MSSNY President Dr. Thomas Madejski stated “We thank the DFS for their efforts to push for legislation to control the ability of PBMs to limit patient access to needed medications. We applaud the extensive review that the DFS provided to this transaction and the conditions they imposed to help minimize the enormous impact that this merger will have on our health care system. We do remain concerned, however, that there may not be sufficient steps imposed to control the enormous power that this merged entity could use to marginalize physician-led medical homes as it expands its corporate driven healthcare model. Physicians fully expect that the merger will further reduce competition in New York’s health insurance market. This is one more reason why physicians deserve the right to collectively bargain against corporate behemoths that seek to limit our ability to deliver needed care to patients.”
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MSSNY Raises Concern with DOH Proposal Regarding Office-Based Surgery Reports
MSSNY has written to the New York State Department of Health to express its concerns and suggested revisions to regulations proposed by the NYSDOH that would require Office-Based Surgery (“OBS”) practices to report cumulative procedural information to NYSDOH. The proposed reporting requirements were published in the New York State Register on October 17 with a 60-day comment period.
The proposed regulation would require each OBS practice to report in a “form and format specified by the Department” information including, but not limited to, practice identifiers, types of procedures, and number of each type of procedure performed in office-based surgery practices. The proposed regulation would also set forth the manner for how adverse events are reported to DOH, as well as grant the DOH discretion to use the data gathered to develop and implement guidelines and criteria for quality improvement.
The MSSNY comments to the NYSDOH note its agreement with the goal of the proposed regulation to help place in context how frequent or rare particular adverse events are occurring in OBS settings, given the importance of quality improvement to assuring patient safety. However, MSSNY expressed concerns with the lack of needed specificity in the proposed regulation, including the specific information OBS practices will be required to report to DOH on an ongoing basis.
Moreover, MSSNY’s comments raise concerns that some practices could find it difficult to report procedural information in a manner to be determined by DOH given that physicians are at different stages of implementing Electronic Health Record (“EHR”) systems. Given the significant EHR implementation challenges facing many physicians, some physicians have either not implemented them or use very rudimentary systems, making a new requirement for the collection and reporting of information difficult to satisfy. Furthermore, there were concerns with the possibility that procedures could be required to be reported by its CPT code, even though some OBS facilities do not internally track these services by CPT code (since they are not submitted to insurance).
Recognizing the goal of the regulation to facilitate quality improvement and patient safety, MSSNY has also suggested that DOH amend the regulation to permit OBS accrediting bodies to file these reports on the physician’s behalf since the information sought by DOH often overlaps with reports that many physicians are already making to their respective OBS accrediting bodies.
US Life Expectancy Decreases Again, CDC Report Finds
On its front page, the Wall Street Journal (11/29) reports data from the Centers for Disease Control and Prevention show that life expectancy for Americans declined again last year by one-tenth of a year, to 78.6 years. An increase in suicides, as well as the continued effects of the opioid crisis, influenza, pneumonia, and diabetes factored into the statistics, the Journal explains.
The data “continued the longest sustained decline in expected life span at birth in a century, an appalling performance not seen in the United States since 1915 through 1918.” The report found “men could anticipate a life span of 76.1 years, down a tenth of a year from 2016,” and “life expectancy for women in 2017 was 81.1 years, unchanged from the previous year.” “Suicides and drug overdoses pushed up U.S. deaths last year, and drove a continuing decline in how long Americans are expected to live.” Dr. Robert Redfield, the director of the CDC, said, “These sobering statistics are a wake-up call that we are losing too many Americans, too early and too often, to conditions that are preventable.”
Claims Data Show Telemedicine Visits Surging in US
JAMA reported that telemedicine visits in the US “have increased sharply,” but “the vast majority of American adults still receive care from doctors in person rather than via remote technology.”
Thirty-two states had passed laws that required parity in insurance coverage and reimbursement for telemedicine by 2016, so the researchers looked at insurance claims data from OptumLabs Data Warehouse for the period from 2005 to 2017 to see how the laws affected those claims. They found telemedicine visits rose from 206 visits in 2005 to “more than 202,000 visits in 2017,” with most of the growth occurring in the last years of the study period. Those visits translated to “an average annual compound growth rate of 52 percent from 2005 to 2014 and an annual average compound growth rate of 261 percent from 2015 to 2017.”
New Online Tool Displays Cost Differences for Certain Surgical Procedures
CMS launched a new online tool that allows consumers to compare Medicare payments and copayments for certain procedures that are performed in both hospital outpatient departments and ambulatory surgical centers. The Procedure Price Lookup tool displays national averages for the amount Medicare pays the hospital or ambulatory surgical center and the national average copayment amount a beneficiary with no Medicare supplemental insurance would pay the provider.
“Price transparency in health care is a priority for the Trump Administration. Working with their clinicians, the Procedure Price Lookup will help patients with Medicare consider potential cost differences when choosing where to have a medical procedure that best meets their needs,” said CMS Administrator Seema Verma.
The Procedure Price Lookup tool is launching as required by Congress in the 21st Century Cures Act. Medicare’s statutes require that CMS maintain separate payment systems for different types of healthcare providers, meaning both CMS and patients may pay different amounts for the same service, depending on the site of care.
Procedure Price Lookup, part of the agency’s eMedicare initiative, joins other patient-oriented transparency tools, including an overhauled version of the agency’s drug pricing and spending dashboards, which provide patients with Medicare and Medicaid spending information for thousands more drugs than ever before and, for the first time, list the prescription drug manufacturers that were responsible for price increases.
CMS recently launched the eMedicare initiative to empower beneficiaries with cost and quality information. This announcement included the launch of an enhanced interactive online decision support feature to help people better understand and evaluate their Medicare coverage options. eMedicare also offers a mobile-optimized out-of-pocket cost calculator to provide beneficiaries with information on overall plan costs and prescription drug costs.
For a blog post on the Procedure Price Lookup took by Administrator Verma, please go here.
Boston Partners Mandates Flu shots for All 74K employees
Boston-based Partners HealthCare is requiring all 74,000 employees to receive flu shots for the first time, reports The Boston Globe.
Under the mandatory flu shot policy, employees who don’t get vaccinated or provide a valid reason for skipping the flu shot could lose their jobs. The policy applies to all hospital-based workers, as well as thousands of employees who work at Partners’ corporate office in Somerville, Mass.
“If you are able and remain unwilling to protect yourself and protect our patients [from the flu], you probably should not be working in healthcare,” Gregg S. Meyer, MD, Partners’ chief clinical officer, told The Boston Globe. “My sincere hope is that absolutely no one will lose their job over it. … We will do everything we can to convince people.”
The policy took effect this fall. So far, 99 percent of employees have received a flu shot or an exemption for religious or medical reasons, Partners officials told The Boston Globe.
Partners modeled the system wide policy on a mandatory vaccination policy Boston-based Brigham and Women’s implemented in 2017.
Johns Hopkins All Children’s Hospital in St. Petersburg, Florida, has notified parents that if their children are not vaccinated, or if they follow an alternative vaccination schedule, that they will be denied medical services. They also notified parents that they will not honor Florida State law that allows for religious exemptions to vaccines.
Unitedhealth Group to Buy Seattle Primary Care Clinic
UnitedHealth Group will acquire a controlling stake in Polyclinic, a large physician-owned primary and specialty care clinic in Seattle — the latest move in the company’s push to expand its direct patient care business, according to The Seattle Times. Under the deal, Polyclinic’s 210-physician practice would merge with Optum Health, a subsidiary of UnitedHealth. The Optum business manages physician groups around the country.
Polyclinic was founded in 1917 by six Seattle physicians and has grown to become one of the largest multispecialty groups in the nation. Despite its ability to scale in size, the practice found it hard to compete with other Seattle area healthcare providers such as Swedish Medical Center and the University of Washington Medical Center.
By merging with Optum, Polyclinic will be able to tackle “the things that you just need to be big enough to afford to do,” UnitedHealth Group CEO David Wichmann told investors during a meeting in New York, according to the Times.
The deal also will expand the clinic’s access to technologies and other physician groups within Optum. The acquisition needs approval from the Federal Trade Commission and would supplement a separate deal with DaVita Medical Group to acquire the 500-physician Everett Clinic, a primary and specialty clinic based in Seattle, and Northwest Physicians Network, a 1,000-plus physician practice in Pierce County, Wash.
It’s OK to Eat Some Romaine Lettuce Again;
Just Check the Label
The FDA narrowed its blanket warning from last week, when it said people shouldn’t eat any romaine because of an E.coli outbreak. The agency reported on November 26 that the romaine linked to the outbreak appears to be from the California’s Central Coast region. It said romaine from elsewhere should soon be labeled with harvest dates and regions, so people know it is good to eat.
Consumers should not eat romaine that doesn’t have the label information, the FDA said. For romaine that doesn’t come in packaging, grocers and retailers are being asked to post the information by the register.
Romaine harvesting recently began shifting from California’s Central Coast to winter growing areas, primarily Arizona, Florida, Mexico and California’s Imperial Valley. Those winter regions weren’t yet shipping when the illnesses began. The FDA also noted that hydroponically grown romaine and romaine grown in greenhouses aren’t implicated in the outbreak.
The labeling arrangement was worked out as the produce industry called on the FDA to quickly narrow the scope of its warning so it would not have to waste freshly harvested romaine. Consumers can expect to start seeing labels as early as this week. It noted that the labels are voluntary and that it will monitor whether to expand the measure to other leafy greens and produce.
The FDA said the industry committed to making the labeling standard for romaine and is considering longer-term labeling options for other leafy greens.
“Evidence-Based Treatment for Tobacco Dependence”
WEBINAR December 4th
REGISTRATION NOW OPEN
Register now for “Evidence-Based Treatment for Tobacco Dependence” webinar on, December 4, 2018 at 7:30 a.m. This program is being jointly sponsored by St. Peter’s Health Partners Community Health Programs; the Medical Society of the State of New York and Glens Falls Hospital Health Promotion Center.
Michael B. Steinberg, MD, MPH, FACP, Director of Rutgers Robert Wood Johnson Medical School Tobacco Dependence Program will serve as faculty for this program. The objectives are for physicians to: 1) Increase their knowledge of seven FDA-approved tobacco treatment pharmacotherapies. 2) Counsel smokers by prescribing tobacco treatment pharmacotherapy to improve their tobacco cessation attempt outcomes including the use of combination therapy. 3) Increase their knowledge in regard to public insurance plans that cover NRTs. 4) Understand the importance of implementing a tobacco dependence treatment policy within their practice which includes the 5As.
This program can be attended either via Webex or at a remote site in the North Country. View the flyer and register here.
This activity has been planned and implemented in accordance with the Accreditation Requirements and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the Medical Society of the State of New York (MSSNY) and St. Peters Health Partners. MSSNY is accredited by the ACCME to provide continuing medical education for physicians.
The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Additional information or assistance with registration may be obtained by contacting Community Health Programs for Webex assistance: (518) 459-2550 – or- for remote site registration contact Shannon Morrison-Gaczol at firstname.lastname@example.org.
The Continued Public Health Threat of Measles: 2018 CME Webinar
December 12, 2018 at 7:30am – Registration now open
In response to the recent and expanding measles outbreaks in New York State, MSSNY has added a just-in-time Medical Matters webinar to our 2018-19 roster. William Valenti, MD, chair of MSSNY Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee will serve as faculty for this program. Registration is now open for this program here.
- Increase physician’s awareness of the role of measles as a re-emerging infection.
- Discuss strategies to improve vaccination rates.
- Explore herd immunity and the role it plays in recent measles outbreaks.
The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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