July 29, 2016 – The Empire Strikes Back

Dr. Reid
Dr. Malcolm Reid

July 29, 2016
Volume 16, Number 27


Dear Colleagues:

We can’t declare victory in the battle against anti-competitive health insurance mergers just yet.

In response to last week’s lawsuit by the US Department of Justice challenging the proposed mergers of Anthem/Cigna and Aetna/Humana, this week Anthem (the parent of Empire) purchased full-page ads in several national papers including the Washington Post, USA Today and the New York Times to present a letter to the public from its chair, Joseph Swedish, that it was “surprised and disappointed” by the DOJ’s actions.

“Given the Justice Department’s flawed analysis and misunderstanding of the dynamic, competitive, and highly regulated health care landscape, Anthem is committed to rigorously defending this transaction in court on behalf of all health care consumers,” Swedish’s letter stated.

Unprecedented in Scale

As reported in last week’s e-news, we are pleased that the DOJ took action to block these takeovers.  In announcing the suit, DOJ noted that the proposed mergers of four of the five largest health insurance companies in the country “are unprecedented in their scale and in their scope” (See the press release here.)

Several state Attorneys General, including New York AG Eric Schneiderman, joined in the litigation to block the proposed merger of Anthem and Cigna.  Specifically, AG Schneiderman noted that “By reducing competition, this proposed merger has the potential to significantly increase the merged firm’s power in the marketplace, to the detriment of consumers. Employers will be left with fewer choices, and ultimately consumers could be saddled with higher premium costs, reduced access to providers, and lower quality care.  I stand with my federal and state partners in fighting to stop this merger before it harms New Yorkers.” (See his full statement here.

The action by DOJ shows the power of organized medicine, particularly when we can work proactively with patient advocates.

We Strongly Oppose Merger

MSSNY along with the AMA, state medical societies, hospital associations and consumer groups have opposed these proposed mergers. Specifically, we argued to both DFS and the AG that the merger between Anthem and Cigna would significantly increase health insurer market concentration in the metropolitan New York City area, and in particular on Long Island. This, in turn, would undoubtedly lead to even greater insurer control of health care delivery and further weaken our ability to advocate on behalf of our patients to assure they have coverage for the care they need.

The AMA’s Advocacy Resource Center (which MSSNY staff sits on its Executive Committee) has been extensively involved in a national campaign to prevent these mergers from going forward.  These efforts included written submissions to the US DOJ in opposition to the mergers, a public relations campaign, and assistance to state medical societies including MSSNY with essential background information that has helped to make compelling arguments to state policymakers regarding the mergers’ potentially significant adverse impact on patients and care providers.

These proposed mergers have also been fiercely opposed by the Coalition to Protect Patient Choice, a group comprised of some of the most powerful patient advocacy groups in New York State and in the country, including 1199, Consumers Union, USPIRG, and Health Care for All New York.

Despite all these efforts, the insurers are clearly not going to walk away from these transactions.  The full page ads this week were likely an effort to demonstrate the financial resources they will expend to fight the action of the DOJ, both in court and in the court of public opinion.

Buckle up.  This could become a bumpy ride.

Malcolm Reid, MD, MPP
MSSNY President

Please send your comments to comments@mssny.org

enews large

CMS Proposes Expansion of Bundled Payments Program for Cardiac Care Episodes
The use of “bundled payments” in Medicare will likely expand once again.  This week CMS announced a proposed rule to create a new Medicare bundled payment model for heart attacks and bypass surgery using 90-day episodes of care.  The program would be applicable in nearly 100 regions across the country, including in the New York City metropolitan statistical area (MSA), as well as in the Elmira, Rochester, Syracuse and Utica MSAs.  The model would be tested for 5-year performance period, beginning July 1, 2017, and ending December 31, 2021.

At the same time, CMS is proposing to expand the existing Medicare Joint Replacement Bundled Payment program implemented earlier this year to cover surgical hip/femur fracture treatment.  The Joint Replacement bundled payment program is currently applicable to 67 MSAs including the Buffalo and New York City MSAs

To read the proposed regulation describing this proposal, click here.

To read the CMS fact sheet describing these new programs click here.

According to the CMS fact sheet, once the models are fully in effect, participating hospitals would be paid a fixed target price for each care episode, with hospitals that deliver higher-quality care receiving a higher target price.   At the end of a model performance year, actual spending for the episode (total expenditures for related services under Medicare Parts A and B) would be compared to the target price that reflects episode quality for the responsible hospital. Hospitals that work with physicians and other providers to deliver the needed care for less than the quality-adjusted target price, while meeting or exceeding quality standards, would be paid the savings achieved. Hospitals with costs exceeding the quality-adjusted target price would be required to repay Medicare.

As with the current hip surgery bundle program, upside and downside risk is limited the first few years of the program, with the amounts at risk to hospitals going up significantly by years 4 and 5 of the program.

Importantly, the CMS proposal would permit these bundled payments in certain circumstance to qualify as an Alternative Payment Model (APM) as set forth in the MACRA law passed by Congress last year.  Participation in an APM “pathway” could enable a physician to not have to participate in the Medicare Merit Based Incentive Payment System (MIPS) program as enacted through MACRA and further spelled out in a regulation proposed by CMS earlier this year. The proposed policy, for which the CMS is seeking comment, would be mandatory and would take effect July 1, 2017. It would affect hospitals in 98 randomly selected metropolitan areas.

The CMS also proposed Monday to expand its first and currently only existing bundled payment model to include hip and femur fractures. That program, which took effect in January, currently covers total joint replacements.

In a bundled payment model, the government reimburses providers a set amount per patient for one episode of care, such as a knee replacement, rather than paying for every individual service rendered as part of that procedure. The idea is to create a financial incentive for providers to better coordinate care and keep costs down.

DSRIP Provider Performance Scorecards (PPS) Ready for Viewing
Fourth-quarter reviews and scorecards for each performing provider system, covering activity through March 31 of this year, have been posted online. In DSRIP Year 1, the PPSs earned about 99.44% of the funds available to them, or $1.2 billion. 

DFS Warns Insurers Not To Create More Restrictive Limits for Mental Health
On July 27, in a new guidance, the New York State Department of Financial Services advised health plans that they cannot create financial requirements or treatment limitations for mental health and substance-use disorders that are more restrictive than the same standards applied to medical and surgical benefits.  

Patient Advocacy Groups to Governor Cuomo:  Sign Step Therapy Override Bill Into Law;
MSSNY representatives joined several other patient advocacy groups in a meeting with Governor Cuomo’s top health policy staff this week to urge that he sign into law legislation (A.2834-D/S.3419-C) supported by MSSNY that would 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.  

In addition to staff, MSSNY was represented by Interspecialty Committee and Committee to End Healthcare Disparities member Dr. Inderpal Chhabra, who spoke regarding the hassles he regularly experiences with some insurers when trying to assure his patients have coverage for the medications they need.  Also joining the meeting were representatives of the NYS Society of Dermatology and Dermatologic Surgery (MSSNY member Dr. Mary Ruth Buchness), the NYS Academy of Family Physicians, the National Psoriasis Foundation, the Global Healthy Living Foundation, National Lupus Foundation, Mental Health Association of New York State, National Alliance on Mental Illness-NY, and the American Cancer Society.

To assist in our collective efforts to convince Governor Cuomo to sign this important bill into law, we ask you send a letter to him in support of this legislation.  A customizable template is available from MSSNY’s Grassroots Action Site here.   We know the insurers are strongly fighting this bill, so the Governor’s office needs to hear your support.

Specifically, 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.

Oscar Will Narrow NY Network to Keep Losses Down
Oscar, the health insurance start-up, plans to dramatically narrow its network in New York, a move aimed at keeping premiums and health care costs in check, according to a blog post from the company’s CEO. (Politico 7/27)

Beginning in 2017, the insurer’s network will have 31 hospitals in three systems — Mount Sinai, Montefiore, and the Long Island Health Network — and 20,000 physicians. That’s down from more than 70 hospitals and 40,000 physicians at the beginning of 2016. NYU Langone and Northwell Health are no longer in network. The insurer had 53,000 members at the end of 2015 and saw a 20% increase in membership during the first quarter of 2016, a boost that likely resulted from the collapse of Health Republic Insurance of New York.

CMS Releases Quality Ratings for Hospitals
CMS released its ratings for about 3,500 hospitals. Under CMS’ quality rating system, medical facilities are assigned “one to five stars based on how well they care for patients,” providing consumers with “a new tool for making health-care choices for themselves and loved ones.”
CMS rated 155 hospitals in New York, but only one of them, the Hospital for Special Surgery in Manhattan, got five stars. Of the remaining 142 hospitals, 49 received three stars, 58 got two stars, and 35 were given one star.

US News & World Report says CMS released the “consumer-friendly hospital star ratings over the objections of hospitals and members of Congress, who call the ratings deeply flawed and say they penalize teaching hospitals and those that treat the poor.”

Last week, in an analysis designed to anticipate and blunt criticism, Medicare reported that 102 hospitals would be given five stars, 934 would receive four stars, 1,770 would get three stars and 133 would get just one star. Nearly one out of five U.S. hospitals – 934 – could not be rated because they treat such small numbers of patients the government couldn’t reliably grade them.

CDC Offering One-Hour Zika Virus Webinar Aug. 10 at 7PM
The Centers for Disease Control and Prevention (CDC) and the American Medical Association (AMA) invite you to join an important webinar focused on Zika virus. CDC Medical Epidemiologist Susan Hills, MBBS, MTH, will present an update on the epidemiological and clinical aspects of the current outbreak. CDC Medical Officer Kiran Perkins, MD, MPH, will present on the implications for pregnant women, including CDC’s updated interim clinical guidance, before fielding questions from webinar participants. Register Here.

Syracuse’s Upstate Medical University announced it will use a five-year, $1 million grant to support a program that seeks to “keep vulnerable populations free of HIV.”

Upstate Med University Granted $1M to Keep Youth Free of HIV
The New York State Department of Health awarded the grant for the school’s new program called “pre-exposure prophylaxis (PrEP) services for general and HIV primary care,” Upstate said in a recent news release.

The program “closely aligns” with Gov. Andrew Cuomo’s “Ending the Epidemic Blueprint2” to reduce the annual number of new HIV infections in New York to 750 by the end of 2020.

The program is available to healthy, HIV-negative adults and adolescents ages 13 and over who are at-risk for HIV and/or sexually transmitted infections (STI).

It is available through Upstate’s Immune Health Services and the pediatric infectious disease/young adult specialized-care center, a program of the Pediatric Designated AIDS Center.

USPSTF: Not enough Evidence for Total-Body Screenings for Skin Cancer
On July 26, the US Preventive Services Task Force [USPSTF] said…that there still isn’t enough evidence to recommend total-body screenings” for skin cancer “and declined to take a position on the practice.” The USPSTF  said “that it could not determine – after reviewing thousands of research papers and studies from around the world – whether the benefits of screening outweighed the potential for harm if unnecessary or excessive procedures were performed.”

Calling Artistic Physicians: Boost Your Clinical Skills with Art!
Join us for MEDICINE AT THE MET: ART IN CLINICAL PRACTICE a new series of ArtMed inSight workshops!

When:  August 12, 2016 from 6 to 8.30pm: Enhancing Observation and Presence

August 13, 2016 from 5 to 7.30pm: Increasing Self-Awareness and Empathic Intelligence

Location: The Met Museum in NYC

Cost:        $125 per;$225 for two

Space is limited! For more information and to register go here. 

Protecting Patient Personal Health Information
Recently, the Centers for Medicare & Medicaid Services (CMS) learned of a potential security breach in which someone was offering for sale over 650,000 records of orthopedic patients. Remember that a covered entity must notify the Secretary of Health and Human Services if it discovers a breach of unsecured protected health information. See 45 C.F.R. § 164.408. Also, keep abreast of any issues that your business associates, especially those entities that provide you with hardware and/or software support for your patient electronic health records. Be sure they are required to report any actual or potential security breaches to you, especially threats that compromise patient PHI.


Brand-New Medical Office for Sale in Lynbrook. Ground Floor in Medical Office Bldg. Parking Available
Close to all area hospitals. Ideal for any specialty. Two spacious exam rooms with sinks, cabinetry and two brand-new exam tables. One consultation room, receptionist’s space, waiting area, one bathroom and lab area. Fully furnished. Asking $125,000 (negotiable). Please email gumd3@aol.com to arrange for a viewing.

Office to Share/Rent
Medical Co-op Building located on East 60th Street, NYC. Includes one consult room and 2 examination rooms, waiting room, 2 bathrooms, plus 2 medical assistants. Space for one secretary. Available 2.5 days per week.  Free internet and Wi-Fi. For more information, contact mamdocs9B@gmail.com or (212) 230-1144.

Want to Rent your Medical Office? Need to Lease Space to Expand your Practice?
Clineeds is an online platform designed to help physicians find or rent medical office space. Listing is completely FREE! Sign up today at http://clineeds.com/signup. We take care of the rest!

Physician Opportunities

Crown Medical PC Needs a New Internist and Pediatrician to Join Our Team! Salary $200,000 + plus benefits.
As a part of our continued growth, we are searching for a new Internist and Pediatrician to join our team. Salary is $200,000 + plus benefits.
Primary Responsibilities:
Examines, diagnoses and treats patients for acute injuries, infections, and illnesses
Counsels and educates patients and families about acute and chronic conditions or concerns
Documents items such as: chief complaint, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment and plan
Formulates diagnostic and treatment plans
Prescribes and administers medications, therapies, and procedures
Orders lab and imaging tests to determine and manage an immediate treatment plan and provides advice on follow up
Responsible for the coordination of care with specialists and appropriate ancillary services
Completes all documentation and paperwork in a timely manner
Maintains quality of care standards as defined by the practice

Required Qualifications:
Active and unrestricted New York medical license
Board certified in Internal Medicine or Pediatrics
Current and unrestricted DEA certificate
Effective communication skills
Outstanding organization skills and ability to multi-task
Takes Initiative, creative, has problem solving ability, is adaptable, and flexible
Ability to work without direct supervision and practice autonomously
Ability to work in fast-paced environment

Nurse Practitioner/ Family Practice Physician
Full time/part time Urgent Care; Primary care/urgent care experience necessary. Rome NY. 315-335-7777

Board Eligible-Board Certified Adult & Pediatric Allergist – Full Time /Part Time MD, DO
Unique opportunity with a successful, established and respected Allergy, Asthma, Immunology and Internal Medicine practice in the prestigious Main Line suburb of Philadelphia. Highly desirable area with award-winning public school systems. Close proximity to Center City Philadelphia, Pocono Mountains, New Jersey Seashore and New York City. Affiliation with an exceptional suburban health system with active residency program.

Academic appointment a possibility. Large-volume practice with established base built on close personal patient relationships. We offer a professional caring environment supported by an experienced dedicated staff. Competitive salary, pension & profit sharing, paid health insurance and med-mal insurance, and CME stipend. Competitive compensation with bonus structure. Partnership/Equity opportunities available after initial period of employment. Send resume to allergypa@aol.com or call 610-649-9300.