July 8, 2016 – Keep Up Advocacy for More Victories!
Dr. Malcolm Reid
July 8, 2016
With your grassroots efforts and working together with strong allies, your MSSNY was able to achieve a number of important legislative victories this past legislative session to reduce your administrative hassles.
However, the need for our continued advocacy on these issues did not end with the Senate and Assembly passing these bills.
We must now turn our attention to pressing the Governor to sign these important bills into law. We need you to send letters to the Governor urging that he sign into the law following bills:
- Legislation 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. A letter can be sent here.
- Legislation that would ease the onerous reporting burden on physicians every single time that they need to issue a paper prescription in lieu of e-prescribing. A letter can be sent here.
- Legislation to permit a pharmacy to transfer an e-prescription to another pharmacy, such as when the initial pharmacy does not have the medication in stock. The letter can be sent here.
The step therapy bill (S.3419-C, Young/A.2834-D, Titone) 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. An insurer decision must be made within 3 days, 24 hours where the patient’s health is in serious jeopardy if they do not receive the physician requested medication.
We know the insurers are strongly fighting this bill, so the Governor’s office needs to hear your support.
The e-prescribing exception reporting simplification bill (S. 6779-B, Hannon/A.9335-B, Gottfried) would allow physicians and other prescribers to make a notation in the patient’s chart when they have had to invoke one of the three statutory exceptions to the mandatory e-prescribing law in lieu of having to report such information to DOH every single time they must write a paper prescription. Currently, 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. This legislation would address this needless burden.
The e-prescription transfer bill (A.10448, Schimel/S. 7537, Martins) would address the situation where a physician must re-submit e-prescriptions to multiple pharmacies if the initial pharmacy receiving the e-prescription is out of stock of the requested for the medication for the patient. 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.
Malcolm Reid, MD, MPP
Please send your comments to email@example.com
MSSNY Files Class Action Suit against United Healthcare re Facility Fees
On July 1, MSSNY and other plaintiffs filed a class action complaint against United Healthcare and its subsidiary and affiliate companies (United) alleging that United has unlawfully refused to pay facility fees to physicians and other health care professionals who perform outpatient surgeries at accredited office based surgery (OBS) practices. The lawsuit was filed in the United States District Court Southern District of New York.
Most United plans allow United insureds to receive insurance benefits from in-network (INET) providers and out-of-network (ONET) providers. The lawsuit concerns United’s handling of ONET claims, and alleges that United’s refusal to pay facility fees to OBS practices violates the terms of United’s plan documents, including the United plan’s “Certificate of Coverage.”
The Certificate of Coverage sets forth the basic terms under which the United plan provides medical/surgical benefits. According to the complaint, United’s standard Certificate of Coverage contains a lengthy list of “Covered Health Services,” including “Surgery-Outpatient,” which is defined in the Certificate as “surgery and related services received on an outpatient basis at a Hospital or Alternate Facility or in a Physician’s office.” In such cases, the Certificate states that the benefits not only include coverage for physician services, but also includes coverage for “facility charge and the charge for supplies and equipment.” According to the complaint, the typical United Plan promises to pay for OBS facility charges, and makes no distinction between facility charges of OBS practices and facility charges of hospitals or other facilities.
According to the complaint, until recently, United honored these plan terms. When a United insured received medically necessary ONET outpatient surgery, United caused the insured’s United Plan to make payment for the surgeon’s services, and another for the facility fee, and the facility fee was paid regardless whether the entity performing the outpatient surgery was a hospital, ambulatory surgery center (“ASC”) or an OBS practice. More recently, however, United has adopted a uniform policy to refuse to pay OBS facility fees, despite the fact that the overwhelming majority of United plans have not changed the terms of the plan’s Certificate of Coverage with respect to ONET outpatient surgeries. The complaint refers to the policy as United’s “Uniform Refusal to Pay.”
The class action complaint alleges that:
- United has systematically violated the terms of the United Plans by adopting its Uniform Refusal to Pay and, among other violations of law;
- United has systematically violated ERISA by failing to honor plan terms and adopting the Uniform Refusal to Pay that violates plan terms.
MSSNY President Malcolm Reid, M.D. stated that United’s Uniform Refusal to Pay is unfair to the many MSSNY physician members who operate OBS practices and the patients they serve, by failing to adequately reimburse OBS practices for the expenses incurred to operate the operating room. In the end, the patients are hurt when the OBS practice is not reimbursed for its facility costs, said Dr. Reid.
The other plaintiffs in the lawsuit include the Society of New York Office Based Surgery Facilities (“NYOBS”) and Podiatric OR of Midtown Manhattan, P.C. MSSNY and NYOBS are seeking injunctive and declaratory relief on behalf of their respective members and patients.
Among the relief requested by the plaintiffs, it is requested that:
- the court issue an order to require United to reprocess all denied OBS claims in compliance with ERISA and the plan terms; and
- to notify all Class Members and all MSSNY and NYOBS members of the right to resubmit claims for services provided through an OBS practice for which facility fees were not submitted in which such facility fees should be covered under the plan terms, and ordering United to reprocess such claims in compliance with ERISA and the plan terms.
The firms Zuckerman Spaeder, LLP and Buttaci & Leardi, LLC represent MSSNY and the other plaintiffs in this action. MSSNY wishes also to thank its general counsel Kern Augustine, P.C. for its advice and counsel.
If you have any questions concerning the litigation, or have issues relating to coverage for OBS fees, please contact Anant Kumar at Zuckerman Spaeder, LLP at firstname.lastname@example.org or by telephone at 646-746-8841.”
New: Survival of Independent Practice Section on the MSSNY Website
MSSNY’s Task Force on Survival of Independent Practice, co-chaired by Thomas T. Lee, MD, and Paul Lograno, MD, was formed last fall based on a directive from the House of Delegates. It was charged with exploring options for independent physicians to collaborate and create practice models to deal with current challenges for independent practices and to achieve the goals of diversity of service, economy of scale and collective negotiations.
The Task Force has put together a series of recommendations on options physicians can consider in order to practice successfully in an independent environment. These are real practice models that have been employed successfully by task force members in different specialties and in different parts of the state and that have made them financially successful and free from many administrative frustrations. They are offered as options for MSSNY members to consider, modify or build on.
Please take a look at the new Survival of Independent Practice site here.
Leadership Seminar Slated for Syracuse Oct 21-22
Following a highly successful Leadership Seminar for downstate physicians in April, MSSNY’s Medical Educational and Scientific Foundation (MESF) has slated a Leadership program for upstate physicians in Syracuse October 21-22.
The program will be held at the Doubletree Inn at NYS Thruway (Syracuse Exit 36). A renowned faculty from Brandeis and Harvard University will lead the program that is focused on management techniques needed by physicians in an integrated health care environment.
Attendees at the April downstate Leadership Seminar gave the program rave reviews. The program is limited to 40 physician attendees aged 40 and under with all costs are covered under a grant from The Physicians Foundation. MESF Chairman Joseph Maldonado MD termed the program a “unique opportunity to hear from an outstanding faculty” and better understand the direction of health care delivery in the next 10 years. To see the agenda and faculty click here. For application forms, contact MESF Executive Director at email@example.com.
CMS’ Slavitt to Testify Before Senate Finance Re MACRA Implementation
Next Wednesday, July 13, at 10 AM, US Senate Finance Committee Chair Orrin Hatch (R-Utah) will convene a hearing on to examine CMS’ implementation of the MACRA law passed by Congress in 2015 to repeal the SGR and creating the MIPS and APM Medicare value-based payment programs. The sole witness for the hearing will be CMS Acting Administrator Andy Slavitt. Video of the hearing will be available here.
Noting that the proposal by CMS to implement the MIPS and APM Medicare value-based payment programs required by MACRA are “far too complex for many physicians who are already drowning in required paperwork from public and private payers”, MSSNY recently 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 joined on to letters to CMS with the Coalition of State Medical Societies and with 110 state and specialty medical societies initiated by the AMA . Both joint letters 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.
While MACRA provides that 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.
- a proposal by CMS that would remove the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey pain management questions from the hospital payment scoring calculation in order to “eliminate any potential financial incentive for doctors to prescribe opioids based on patient experience survey questions;”
- a final rule issued by the Substance Abuse and Mental Health Services Administration (SAMHSA) that would increase from 100 to 275 the number of patients a physician can treat with buprenorphine; and
- a new policy that would require Indian Health Service (IHS) prescribers and pharmacists to check state Prescription Drug Monitoring Program (PDMP) databases before prescribing or dispensing opioids for pain.
To read the full press release, click here.
House Passes Legislation to Overhaul Mental Health System
The House passed legislation on July 6 to overhaul the nation’s mental health system, the first effort by lawmakers to specifically tackle federal policies on serious mental illness. The bill passed 422-2, overwhelming support that reflected a decision by sponsors to defer debates on some of its most controversial aspects. The bill would reorganize the federal agency overseeing mental health policy, direct funding to combat serious mental illness as opposed to general mental health programs, and change Medicaid reimbursements for treating patients with illnesses like schizophrenia.
The bill passed Wednesday would require the Health and Human Services Secretary to seek public comment and write new regulations on how to handle privacy law in cases of serious mental illness. It would also reauthorize grants for states that already run compelled treatment programs and largely drop restrictions on patient advocacy groups’ work.
It would also boost requirements for private insurers to cover mental health care on an equal footing with physical health, and open official studies on other areas that could support changes in the future. One boost for the House bill came Tuesday from the Congressional Budget Office, which said the measure wouldn’t increase federal spending, and would reduce spending on the Medicaid program by $5 million over 10 years. (Modern Healthcare, 6/28)
Important Reminder about Billing Requirements for Certain Dual-Eligibles
As part of the AMA’s ongoing work with the Centers for Medicare & Medicaid Services on issues affecting Medicare providers and beneficiaries, the AMA would like to remind physicians that balance billing is prohibited for Medicare beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program. CMS has conveyed their concern that some physicians are still billing QMB beneficiaries, despite the existing prohibition.
The QMB program is a Medicaid program that helps very low-income dual eligible beneficiaries—e.g., individuals who are enrolled in both Medicare and Medicaid—with Medicare cost-sharing. Beneficiaries in the QMB program have annual incomes of less than $12,000. Federal law protects QMBs from any cost-sharing liability and prohibits all original Medicare and Medicare Advantage providers—even those who do not accept Medicaid—from billing QMB individuals for Medicare deductibles, coinsurance, or copayments.
All Medicare and Medicaid payments that physicians receive for furnishing services to a QMB individual are considered payment in full. It is important to note that these billing restrictions apply regardless of whether the state Medicaid agency is liable to pay the full Medicare cost-sharing amounts (federal law allows state Medicaid programs to reduce or negate Medicare cost-sharing reimbursements for QMBs in certain circumstances). Physicians may be subject to sanctions for failing to follow these billing requirements, and CMS has indicated that they may start conducting more frequent audits to address this practice.
For further information, see MLN Matters, Prohibition on Balance Billing Dually Eligible Individuals Enrolled in the Qualified Medicare Beneficiary (QMB) Program.
FDA Approves First Hepatitis C Drug That Treats All Six Strains
The Wall Street Journal (6/28) reports that the Food and Drug Administration has approved Gilead Sciences Inc.’s Epclusa (sofosbuvir/velpatasvir), the first drug that treats all six strains of hepatitis C. According to Gilead, the drug’s list price will be $74,760 for a course of treatments, which is lower than its older hepatitis C treatments. The AP (6/28, Perrone) reports that Epclusa “cures 95 percent of patients in three months, according to clinical trial data reviewed by the FDA.” It is “designed to be used in combination with ribavirin, an older antiviral drug.”
Additional coverage is provided Bloomberg News (6/28), MedPage Today (6/28).
Oxford pulls more plans from NY market
Oxford Health Plans is leaving the individual market in New York in 2017, and also plans to discontinue its small and large group products, UnitedHealthcare announced in a notice to brokers last Friday. While United indicated in the letter that few large groups currently offer an Oxford plan, the loss of the Liberty Network HMO plans and Oxford Metro Network plans will likely leave significant gaps in the small-group and individual markets, respectively, said Alex Miller, a partner at Millennium Medical Solutions, an employee-benefits consulting agency based in Westchester County. “In the last five years, the Liberty HMO has been our most popular product,” he said. But Oxford has requested high premium increases for its small-group plans in recent years, including an average rate hike of 10.58% for 2016.
Instead, the state approved an average increase of 3.9%. BlueCross BlueShield exited New York’s small-group market a few years ago, but is considering re-entering to pick up Oxford’s members, Miller said.
EmblemHealth and 13 oncology practices across New York State are participating in an experimental care delivery model, the U.S. Department of Health and Human Services announced Wednesday. Read the HHS press release here.
New York’s Zika Numbers on the Rise
The State Health Department reported that as of Tuesday, there were 260 confirmed cases of Zika in New York City, and 74 in the rest of the state. State health officials said there are no cases of reported microcephaly in the state. Speaking on a conference call with reporters on July 1, Dr. Bassett said 24 of those cases were pregnant women for whom Zika can be especially dangerous because of the virus’ effects on the fetus.
FDA: Do Not Eat Raw Cookie Dough Due to E.coli Contaminated Flour
On July 6, the FDA issued a message warning people not to eat raw dough because of a recent outbreak of E. coli linked to contaminated flour.
So far, a reported 38 people in 20 states have been infected by a strain of bacteria called Shiga toxin-producing E. coli O121 found in flour. The infections began last December, and 10 of those infected have been hospitalized.
Symptoms of the bacterial infection include severe stomach cramps, diarrhea (often bloody), and vomiting. Most people get better within a week, but in some cases, infections can lead to a type of kidney failure called hemolytic uremic syndrome. Those who are most vulnerable to severe illness include children under 5, older adults and people with weakened immune systems.
Investigations by the Centers for Disease Control and Prevention and the FDA traced the source of the outbreak to flour that was produced in November 2015 at the General Mills facility in Kansas City, Mo. General Mills has issued a voluntary recall of 10 million pounds of flour produced between Nov. 14 and Dec. 4, sold under three brand names: Gold Medal, Signature Kitchens and Gold Medal Wondra. Flour that is part of the recall should be thrown away.
Unlike other raw foods, like eggs or meat — which many people recognize as contamination risks — “flour is not the type of thing that we commonly associate with pathogens,” said Jenny Scott, a senior adviser in the FDA’s Center for Food Safety and Applied Nutrition.
In this case, investigators believe that the grain became contaminated in the field, where it is exposed to manure, cattle, birds and other bacteria. “E. coli is a gut bug that can spread from a cow doing its business in the field, or it could live in the soil for a period of time; and if you think about it, flour comes from the ground, so it could be a risk,” said Adam Karcz, an infection preventionist at Indiana University Health in Indianapolis.
MACRA Rule Raises Patient Privacy Concerns
Physicians and healthcare organizations have flooded the CMS with concerns about MACRA, the proposed changes to the way Medicare pays providers. They say the rule puts patient data at risk and could actually push providers away from participating in payment models meant to lower costs while increasing quality of care. (Modern Healthcare 6/28)
The Medicare Access and CHIP Reauthorization Act aims to consolidate three existing payment models: the Physician Quality Reporting System, the Physician Value-based Payment Modifier and Medicare’s incentive program for achieving meaningful use of electronic health records.
Agency officials said the new consolidated program will offer physicians greater simplicity and flexibility, providing two paths for physician payments when it goes into effect in 2019. Physicians can choose to participate in the Merit-based Incentive Payment System, or MIPS, or have a significant amount of their revenue generated under a qualifying alternative payment model, or APM.
The agency received nearly 4,000 comments by the June 27 deadline. The majority of comments were critical of the proposed rule.
Several providers said a requirement to submit quality information via a registry or EHR oversteps by asking providers not only for data on Medicare patients, but patients with other forms of coverage as well. Experts say providers are raising a valid point.
Others say the rule could discourage providers from participating in value-based purchasing initiatives. For instance, to quality for a 5% bonus, providers must participate in models that require significant financial risk.
“Although the clinicians participating in shared savings-only models are working hard to support CMS’s goals to transform care delivery, under CMS’s proposal they will not be recognized for those efforts,” Tom Nickels, the American Hospital Association’s executive vice president of government relations and public policy, said in a statement
“We fear this could have a chilling effect on experimentation with new models of care among providers that are not yet prepared to jump into two-sided risk models.”
Providers across the country said the 963-page rule is simply too complex to understand, making it difficult to adhere to.
The rule is expected to be finalized by Nov. 1.
NIH Awards $55 Million to Build Million-Person Precision Medicine Study
The National Institutes of Health announced $55 million in awards in fiscal year 2016 to build the foundational partnerships and infrastructure needed to launch the Cohort Program of President Obama’s Precision Medicine Initiative (PMI). The PMI Cohort Program is a landmark longitudinal research effort that aims to engage 1 million or more U.S. participants to improve our ability to prevent and treat disease based on individual differences in lifestyle, environment and genetics. The project is expected to launch later this year.
The awards will support a Data and Research Support Center, Participant Technologies Center and a network of Healthcare Provider Organizations (HPO). An award to Mayo Clinic, Rochester, Minnesota, to build the biobank, another essential component, was announced earlier this year. All awards are for five years, pending progress reviews and availability of funds. With these awards, NIH is on course to begin initial enrollment into the PMI Cohort Program in 2016, with the aim of meeting its enrollment goal by 2020. The PMI Cohort Program is one of the most ambitious research projects in history and will set the foundation for new ways of engaging people in research. PMI volunteers will be asked to contribute a wide range of health, environment and lifestyle information. They will also be invited to answer questions about their health history and status, share their genomic and other biological information through simple blood and urine tests and grant access to their clinical data from electronic health records. In addition, mobile health devices and apps will provide lifestyle data and environmental exposures in real time. All of this will be accomplished with essential privacy and security safeguards. As partners in the research, participants will have ongoing input into study design and implementation, as well as access to a wide range of their individual and aggregated study results. (NIH News, 07/08/2016
CDC Issues Alert on Multidrug-Resistant Yeast
U.S. healthcare facilities should be alert for Candida auris — an emerging multidrug-resistant yeast that causes invasive disease and carries a high mortality rate — the CDC has warned.
Since 2009, C. auris infections — including bloodstream, wound, and ear infections — have been identified in Africa, Asia, Europe, and South America. In addition, an isolate was identified in the U.S. in 2013. Patients usually become infected several weeks into their hospital stay. The organism appears to spread within healthcare facilities, although the exact mechanism is unknown. Some 60% of infected patients have died, the CDC reports. However, this figure is based on limited case numbers, and many patients had other conditions that put them at increased mortality risk.
Almost all tested isolates have been resistant to fluconazole, more than half resistant to voriconazole, one-third resistant to amphotericin B, and several resistant to echinocandins. Some isolates have been resistant to all three major classes of antifungal drugs.
Commercially available biochemical tests cannot differentiate C. auris from other Candida species; accordingly, the CDC offers advice on laboratory diagnosis at the link below. The agency also advises healthcare facilities on case reporting, patient isolation, and appropriate environmental cleaning.
CDC clinical alert (Free)
CDC Q&A on C. auris (Free)
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 call 516-259-1877 to arrange for 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?
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Medical Office For Rent – 715 West 170 Street
Two to five examination rooms available plus Reception,secretarial areas. Two bathrooms and entrances. Ethernet and cable ready. $4000 – $9500/ month. 917.861.8273 firstname.lastname@example.org Can build to suit including accredited O.R.s
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.
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
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
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 email@example.com or call 610-649-9300.