August 18, 2017 – NYTimes Editorial WRONG!


PRESIDENT’S MESSAGE
Charles Rothberg, MD
August 18, 2017
Volume 17
Number 32

Dear Colleagues:

Today’s New York Times editorial in support of legislation to expand malpractice lawsuits is an affront to every physician in New York State.  The editorial board members should be ashamed to look their doctors in the eye the next time they need their services, which they apparently must take for granted.

We have sent a response to the Times that highlights the threat to patient care this bill would undoubtedly bring about should it be signed into law.  Their editorial completely ignores this risk, despite the fact that we were recently named the worst state in the country to be a physician, and despite the fact that surveys of hospital Emergency Departments across the state have shown that many do not have sufficient on-call specialty care to meet expected patient demand.

They also repeat the tired line of New York being only one of a handful of states without such “date of discovery” exceptions to their statute of limitations law, without at all acknowledging that most other states with such laws have limitations on damages to balance these costs.

They also failed to acknowledge that the situation involving Lavern Wilkerson was the result of the application of the much shorter statute of limitations for municipal hospitals as compared to private hospitals.  As I have repeatedly stated, were the circumstances involving Lavern’s case to occur at a private hospital, she would have had ample time to sue her doctors and hospitals.

Rather than advancing legislation to correct that imbalance, trial lawyers have manipulated the issue to bring us to the verge of a huge explosion of lawsuits, at a time when physicians cannot take on any new costs.  And patient care in New York is bound to suffer.  In addition to more payouts, there will also be an explosion of meritless litigation given the drafting errors in this bill that may cause this legislation to apply to far more cases than simply alleged misdiagnoses of cancer.

Apparently, the New York Times does not care.

I am a regular reader of the Times.  I find it ironic that the Times will often warn their readers about the importance of understanding an issue comprehensively rather than simply reacting emotionally; yet when it comes to medical malpractice legislation they are clearly viewing this issue through one lens only.

We must continue to make the public aware of the damage this bill will cause to our healthcare system.  In this regard, I want to thank the many physicians across the State who have taken the time to send op-eds to their local papers warning of the consequences to care in their communities.  Some examples are here , here and here.  We anticipate that many more will be published in the near future.

I also want to thank the many physicians who have taken the time to contact the Governor.  Physicians should continue to do by calling his office at 518-474-8390 and sending a letter here.

Since this bill has not yet been officially delivered for his consideration, it is clear that the Governor and his staff are trying to be very thoughtful in their analysis of legislation.

With all the problems in our health care system, and still facing the possibility of huge cuts coming from Washington, we cannot tolerate any new costs.  We urge Governor Cuomo to veto this legislation and work to develop legislation that both addresses the Lavern situation and establishes needed systemic reforms to better assure timely patient access to care.

Sincerely,
Charles Rothberg, MD
MSSNY President

Please send your comments to comments@mssny.org


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DFS Announces Insurance Premium Rates for 2018; Slight Decrease from Insurers Requests
Individual health insurance premium rates will increase 14.5%, and small group premiums will increase 9.3%, according to an announcement this week from New York Financial Services Superintendent Maria Vullo.  The DFS press release noted that it reduced the insurers’ requested 2018 rate increases by more than 3.8 % overall for the 300,000 enrolled in individual plans.  For small group plans, with more than 1 million insureds, DFS reduced insurers’ requested 2018 rate increases by 2.4%.

The press release noted that the premiums were set despite the uncertainty regarding the continued availability of the ACA’s Cost Sharing Reduction (CSR) subsidies for insurers. Specifically, it was noted that “ DFS will continue to fight for payment of the CSRs so that consumers are not further harmed by federal government actions. However, in light of the ongoing uncertainty regarding CSR payments by the federal government… DFS is granting an additional rate factor based on information that insurers had provided to DFS in May 2017 that estimated potential funding loss. The additional factor only applies to the individual rates of silver plans.”

The press release further noted that “Underlying medical costs continue to be the main drivers of premium rate increases, reflecting a nationwide trend. For the 2018 individual rates announced today, drug costs account for the largest share (26 percent) of all medical costs, with specialty drug costs increasing about 49 percent. Inpatient hospital costs account for the second largest share of medical expenses (19 percent), followed by physician specialty services (12 percent) and diagnostic testing/lab/x-ray (10 percent).”

For a full listing of the premium rates requested and approved on a company by company basis, please view the press release here.


AG Announces Joint State-Federal Settlement with Maker of Epipens
New York Attorney General Eric Schneiderman announced this week that New York State had agreed to join a state-federal $465 million settlement with drug maker Mylan to resolve allegations that Mylan knowingly underpaid rebates owed to Medicaid for EpiPens that were dispensed to Medicaid beneficiaries. Under the settlement, New York will receive $38.5 million.

To read the AG’s press release, click here.  The press release notes that the settlement resolves allegations that Mylan submitted false statements to the Centers for Medicare and Medicaid Services (CMS) and several states reliant on EpiPen rebates, and knowingly underpaid its obligations for Medicaid drug rebates to the State Medicaid Program for EpiPens.

DFS Issues Transgender Health Guidance to Health Plans
NYS DFS issued guidance on transgender health in a circular letter to health plans.  The letter advises plans to request additional information before denying benefits for procedures that are not routinely provided to a specific gender. Insurers may not discriminate against transgendered or gender non-conforming individuals who file health claims for conditions that are not normally associated with the gender with which they identify. The circular letter is here.


2017 MSSNY Continuing Medical Education Provider Conference
To meet the challenges facing planners, providers and participants of CME, MSSNY recognizes the need for ongoing education and training of its Accredited Providers as well as physicians and other healthcare professionals in NYS. This conference will inspire participants to explore and interactively address challenges such as self-directed learning for physicians and compliance with the changing accreditation criteria that clearly address practice gaps and practice-based needs while creating opportunities for measurable change in physicians and reinforcing the undeniable link between a successful CME activity and quality improvement for physicians and patients alike.

The conference will take place on Friday, September 15, 2017, at the Westbury Marriott.  The program is scheduled from 7:30 AM to 3:45 PM.  Registration links and more information are available here.  Featured speakers include Steve Singer, PhD; Vice President of Education and Outreach, Accreditation Council for Continuing Medical Education (ACCME) and Mary Kelly, Project Administrator, AMA PRA Standards and Policy.  MSSNY President Charles Rothberg, MD will deliver the welcome and opening remarks. For more information, please contact Miriam Hardin at mhardin@mssny.org. Our flyer with information is here.

MSSNY Counsel Don Moy: Please Read the 2018 Family Leave Law
Virtually every employer in NYS must start preparing for phased in implementation of the NYS Paid Family Leave law, which begins in 2018.  The State of New York website gives detailed summaries regarding the law, and the obligations of employers and employees under the law.  Perhaps the attached information can be helpful in the event a medical practice or county medical society is not aware of this website.


FREE Drug Discount Card for Your Patients

Many of your most vulnerable patients have trouble affording medication. The New York Rx Card can help with those prescription costs and is a free program available to all New York residents. There are no eligibility requirements or forms to fill out. Tell your patients to simply take the card into the pharmacy to get savings of up to 75% on prescription medications for their whole family. New York Rx Card is a proud supporter of Children’s Miracle Network. A donation will be made to your local CMN hospital each time a prescription is processed through the New York Rx Card. Your patients can find and print their FREE card here!



DOH Releases Children’s Medicaid Transformation Plan
The state released a draft plan on August 16 regarding how it will transform the children’s Medicaid program and transition children currently covered by fee-for-service Medicaid to managed care plans. The transformation of the children’s Medicaid system is intended to improve access to care for high-needs children, according to the document. One way the state aims to do that is by consolidating the six waivers currently authorizing home- and community-based services for children into a single waiver. It also aims to shift more children in need of care management for chronic conditions, including behavioral health issues, into health homes. Currently there are 16 health homes across the state that have been designated to serve children. (Crains 8/16)


Your membership yields results and will continue to do so. When your 2018 invoice arrives, please renew. KEEP MSSNY STRONG!


CMS Announces End to Two Mandatory Bundled Payment Programs, and Proposes Rollback to Joint Replacement Program
CMS announced this week that it was intending to cancel two of its Medicare bundled payment demonstration programs and make substantial changes to a third program. Specifically, the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model announced last year would be cancelled, and the number of regions across the country required to participate in the Comprehensive Care for Joint Replacement (CJR) model adopted in 2015 would be cut in half.

To read the full press release, click here.

The EPM and Cardiac Rehabilitation Incentive Payment models were scheduled to begin in January 2018. CMS stated that it was proposing to eliminate these two models to give the agency “greater flexibility to design and test innovations that will improve quality and care coordination across the in-patient and post-acute-care spectrum.”  According to the press release, CMS expects in the future to “increase opportunities for providers to participate in voluntary initiatives rather than large mandatory episode payment model efforts.”

Moreover, the number of regions required to participate in the Joint Replacement bundled payment program was cut from 67 to 34.  Hospitals in the other 33 regions could continue to participate voluntarily. To read the entire proposed rule, click here.  Based upon an initial review of the rule, it appears the Buffalo metropolitan area has been removed entirely from mandatory participation in this program (p.26)   While the New York City metropolitan area will remain in the mandatory program, several hospitals in the MSA have been exempted from voluntary participation (p. 27).

MSSNY Travel Discount Program
MSSNY is pleased to offer an exclusive worldwide travel discount service to our members. Savings average 10-20% below-market on all hotels and car rental suppliers around the world.

Save time and money.  Let Local Hospitality negotiate the best deals and comparison price for you.  Any hotel, any car, anywhere, anytime. Click here to save on your next trip.

Survey: Medical Groups Find Complying with MIPS Extremely Burdensome
A recent survey by Medical Group Management Association (MGMA) has found that most physician practices are finding it challenging to comply with the Merit-Based Incentive Payment System (MIPS). Approximately 82% of medical practices identifies the system as “very” or “extremely” burdensome.  Responding medical groups also noted health information technology as a major inhibitor in their ability to provide quality patient care.  The survey includes responses from 750 group practices with the largest representation among independent medical practices and in groups with 6 to 20 physicians.

Reminder: Medicaid Billing for Prescription Drugs when Prescribed by Unlicensed Residents, Interns and Foreign Physicians in Training
The purpose of this article is to provide a reminder regarding NYS Medicaid’s billing requirements for drugs when prescribed by unlicensed residents, interns and foreign physicians in training only.

  • NYS Medicaid accepts prescriptions written by providers legally authorized to prescribe per NY Education Law, Article 131, Section 6526, and 10 NYCRR 80.75(e). This includes unlicensed residents, interns and foreign physicians in training programs, under the supervision of a NY State Medicaid enrolled physician.
  • In accordance with NY Education Law, NYS Medicaid does NOT require the name and signature of the supervising physician to be included on the prescription.
  • Effective January 2014, NYS fee-for-service Medicaid implemented claims editing that enforced the OPRA requirement for healthcare professionals, practice managers, facility administrators, and servicing/billing providers.
  • Because NYS Medicaid’s provider enrollment system can only accept licensed providers, pharmacy claims for services ordered by unlicensed residents, interns and foreign physicians in training programs reject when initially submitted for payment.

The following two (2) options continue to be available to pharmacies, to enable payment for prescription drug claims when prescribed by unlicensed residents, interns and foreign physicians in training only:

  1. Resubmit the claim using the National Provider Identifier (NPI) of the enrolled NYS Medicaid provider (the intern or resident’s supervising physician) as the secondary NPI.
  2. In the event the pharmacy’s billing system is limited to submitting only one prescriber NPI number, or the NPI number of the supervising physician cannot be obtained, then use the urgent/emergency override option (outlined below).

Directions for Urgent/Emergency Override

If you have a prescription written by an unlicensed resident, intern or foreign physician in a training program you will receive a reject code of “56” via NCPDP transaction stating the provider has a non-matched Prescriber ID listed in NCPDP field number 511-FB.

In the case of claims for items prescribed by unlicensed residents, interns or foreign physicians in training programs, pharmacies can provide the medication and receive reimbursement by resubmitting the claim using the following emergency override procedure:

In the Reason for Service Code Field (439-E4) also known as the Drug Utilization Conflict Field – enter “PN” (Prescriber Consultation) In the Result of Service Code Field (441-E6) – enter one of the following applicable values (1A, 1B, 1C, 1D, 1E, 1F, 1G, 1H, 1J, 1K, 2A, 2B, 3A, 3B, 3C, 3D, 3E, 3F, 3G, 3H, 3J, 3K, 3M, 3N, or 4A)

In the Submission Clarification Code Field (420-DK) also known as the Drug Prescription Override Field – enter “02” (Other Override).

Please note that the above override should NOT be used for a licensed prescriber who has not yet enrolled in NYS Medicaid. In the event of a prescription being sent by a non-enrolled licensed prescriber, the prescriber should be encouraged to enroll in the NYS Medicaid Program. Information regarding how to enroll can be found here.

Medicaid Fee-For-Service (FFS) to Systematically Enforce Legislation Limiting Initial Opioid Prescribing to a Seven Day Supply
In accordance with New York State Public Health Law, effective August 24th, 2017, the Medicaid FFS program will be implementing a seven (7) day supply limit on initial opioid prescribing for acute pain. This is a change from the current editing, implemented on December 5, 2013, which set the limit to a fifteen (15) day supply on initial opioid prescriptions. Information on this legislation can be found on page 6 of the July 2016 Medicaid Update.

Prior authorization (PA) will be required for claims that do not meet the above criteria.

To obtain a PA, please contact the clinical call center at 1-877-309-9493. The clinical call center is available 24 hours per day, 7 days per week with pharmacy technicians and pharmacists who will work with you, or your agent, to quickly obtain a PA.

The most up-to-date information on the Medicaid FFS Pharmacy Prior Authorization (PA) Programs and a full listing of drugs subject to the Medicaid FFS Pharmacy Programs can be found here and here.

Medicaid enrolled prescribers can also initiate PA requests using a web-based application. PAXpress® is a web based pharmacy PA request/response application accessible here.



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