July 31, 2015 – Facts v. Perceptions in JAMA’s ACA Study

 Dr. Joseph R. Maldonado
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July 31, 2015
Volume 15, Number 29

Dear Colleagues:

This week, the Journal of the American Medical Association published the findings of a survey which, among other goals, sought to ascertain the nature of changes in access to care, and the health of patients during the first two enrollment periods of the ACA. In addition, the survey wanted to identify differences for low-income individuals in states that expanded Medicaid versus those that did not.  The authors point out the importance of the survey findings for development of future health policy. Sadly, the survey merely serves to highlight the dangers in failing to follow fundamental evidence-based research principles.  If the results are used as intended by the authors, the astute clinician with good critical appraisal skills will understand how flawed research design leads to flawed health policies.

Flawed Core Design

The development of a clear and answerable question is at the core of study design.  Moreover, the findings must be relevant and applicable to the research subjects and/or to the beneficiaries of the study findings.  The study’s questions, methods and findings all fail the relevancy test. A critical appraiser should reject the conclusions of the authors, especially as they are unsuitable for policy development.  “Perceived” patient access to care does NOT equate to access to care.  The ACA may have given more Americans the ability to purchase health insurance. However, having an insurance card, especially a Medicaid product, does not translate to being able to find a doctor to treat you.

“Insurance card access” says nothing about actual access. Will a newly acquired Medicaid card be equal to, better or worse than the care they may have received without insurance or with a non-Medicaid insurance product?  Are these patients actually accessing doctors?  Does the patient’s perception of the quality of care meet the perceptions of other patients with non-Medicaid insurance products? Questions based on patient perception of these matters are important but they should not be the central drivers of health policy.

Evidence of Access Problems

Policy needs to be grounded in more scientifically valid observations— not patient bias.  However, if the goal is to pander to public perceptions to promote health policy that has other agendas as their drivers, then “perceived” improvements in healthcare or access will suffice.  There is growing evidence that access to care is a problem for patients who have signed onto ACA health insurance products.

We now have the data to study access to care based on claims.  Insurance carriers can certainly provide deep data on complication rates, readmissions, and other outcomes.  If we want to develop sound health policy while assessing the current outcomes of patient care under the ACA, let’s do so based on evidence extracted from well-designed studies that are truly relevant to meaningful health policy development.

Perception of care is not delivered medical care. Let’s begin the future with the facts.

JAMA study

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President

Please send your comments to comments@mssny.org


Please Take Just a Few Minutes to Complete our Health Insurance Hassles Survey
If you have not already, we urge you to take the opportunity to complete our latest health insurance hassles survey.  To complete the survey, click here.   It should take no more than just a few minutes.  Some of the initial findings of our survey include:

  • Many physicians see patient access to Out of Network coverage shrinking. 33% of the respondents indicated that they treat far fewer patients with out of network coverage than they did 3 years ago, and over 40% indicated that their patients’ OON insurance cover far less of a patients’ medical costs than it did 3 years ago
  • Health plan online participating provider lists are often inaccurate. 45% of the respondents indicated that they were erroneously listed as a participating provider on a health insurer’s website
  • Payments by Exchange plans are poor. Over 75% of the respondents indicated that Exchange plans paid them less than other commercial insurance products, with over 50% noting that the payments were “significantly lower” than payments for other plans offered by that insurer.
  • Health plans are shrinking their networks. Over ¼ of the respondents noted that there were not asked to participate in a new health insurance products offered by a plan with which they participated, with the overwhelming number of respondents noting that the reason was because the plan wanted to offer a “narrow network”.
  • Significant numbers of patients now have hefty deductibles. Nearly 20% of the respondents noted that patients with deductibles of $5,000 or greater comprised 10-25% of their practice, while 32% noted patients with deductibles between $2,500 and $5,000 comprised another 10-25% of their practice; and nearly 40% noted that patients with deductibles between $1,000 and $2,500 comprised another 10-25% of their practice.

These surveys help us to fully understand physician concerns with the contracting process between physicians and these health insurers. The findings also assist MSSNY’s advocacy efforts in the media and with policymakers to support fair contracting, comprehensive health insurer networks and comprehensive out of network coverage.

However, we need a representative cohort of physicians to respond to this survey is we are to be successful in advocating on yours and your patients’ behalf.  Please take just a few minutes to share your perspective.

United Healthcare and In-Network Labs
Effective September 1, 2015, UHC will require its network physicians and other qualified healthcare professionals in NYS to refer to or use network laboratories and pathologists for UHC Oxford NY members.  Any questions? Call United Healthcare Oxford network Laboratory Services Manager, Catherine Schaal at 631-584-0152.

55 Million Enrolled in Medicare; 3.3 Million in New York
55 million Americans are now covered by Medicare, according to a press release issued by CMS this week recognizing the 50th anniversary of Medicare and Medicaid.   The press release noted that there are over 3.3 million New Yorkers enrolled in Medicare, with over 2 million enrolled in traditional Medicare, and 1.25 million enrolled in Medicare Advantage plan.  Moreover, over 2.5 million New Yorkers have prescription drug coverage through Medicare, broken down between nearly 1.4 million enrolled in a Part D plan, and over 1.1 million enrolled in a Medicare Advantage plan with drug coverage. 

Over 2 million New Yorkers Enroll in Exchange; Nearly 75% is Medicaid
2.1 million New Yorkers enrolled in a health plan via the New York State Health Insurance Exchange, according to data released this week by the New York State of Health..  The data indicated that nearly ¾ of that 2.1 million, 1,568,345, were enrolled in Medicaid, with 159,716 enrolled in Child Health Plus, and 415,352 enrolled in commercial health insurance coverage.

The data also showed 9 health insurers enrolled 5% or more of total statewide commercial health insurance enrollees, led by Fidelis Care (20%), Health Republic (19%), Healthfirst (10%) and Empire Blue Cross Blue Shield (10%).  Of great concern, out of network coverage benefits were only available in 11 counties, with 21% of the enrollees in those counties selecting this coverage.   This lack of out of network coverage is exacerbated by the problem many consumers and physicians have reported regarding Exchange plans having inadequate physician networks to meet patient care needs.  Therefore, MSSNY continues to seek legislation (S.1846, Hannon/A.3734, Rosenthal) to require health insurers to offer out of network coverage in New York’s Exchange.

The overwhelming majority (58%) of those who received coverage in the Individual market were enrolled in Silver plans, while 18% enrolled in Bronze plans, 12% enrolled in Platinum plans, 10%  enrolled in Gold plans, and 2% enrolled in Catastrophic plans.  The State also reported that 55% percent of enrollees in the Individual market are in health plans with no annual deductible or deductibles of $600 or less.

While the overwhelming percentage of commercial health insurance coverage enrollment was in the individual market, the data indicated that 3,700 small businesses across New York State had procured coverage through the State Business Marketplace (SBM), providing coverage to nearly 15,000 employees and dependents.   Platinum plans were the most popular plan selected in the SBM representing over one-third of total enrollment. Gold and silver plans had enrollment at 27% and 26%, respectively, and only 13 % of SBM enrollees chose Bronze plans. 

Funding Opportunities Date Extended for Doctors Across New York
The New York State Department of Health, Office of Primary Care and Health Systems Management has made revisions to the Cycle IV Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Funding Opportunity. The DANY application submission deadline has been extended to Monday, August 31, 2015. Applicants can, and are encouraged to, submit prior to the August 31st deadline.

For other revisions, please refer to the New Program Changes (Supersedes all other document references) bullet on the website.

Legionnaires Disease Outbreak in South Bronx
NYCDOHMH is reporting an outbreak of Legionnaires’ disease in the South Bronx, resulting in two deaths. There have been 31 reported cases since July 10, compared with five confirmed cases during the same period in 2013 and 2014, combined. The rate of Legionnaires’ disease in the Bronx during 2015 has been 3.9 per 100,000 residents, more than twice the rate of the rest of the city. In High Bridge-Morrisania and Hunts Point-Mott Haven, the rate is 8.8 per 100,000. Dr. Jay Varma, New York City’s Department of Health and Mental Hygiene Deputy Commissioner for Disease Control, said what is “unique and important” about the recent outbreak is the “dramatic increase in one specific area.” Officials had noticed an initial uptick in cases last week followed by a large increase over the weekend.

Legislation Introduced in Congress to Address Burdensome Meaningful Use Requirements
This week U.S. Representative Renee Elmers (R-NC) introduced legislation (H.R. 3309, the Further Flexibility in HIT Reporting and Advancing Interoperability Act, or Flex-IT 2 Act) to reduce the overwhelming burdens physicians are facing with complying with federal EHR meaningful use requirements.   A press release by Rep. Ellmers noted that the bill would accomplish the following:

  • Delay Stage 3 Rulemaking until at least 2017, or MIPS final rules or at least 75 percent of doctors and hospitals are successful in meeting Stage 2 requirements.
  • Harmonize reporting requirements (MU, PQRS, IQR) to remove duplicative measurement and streamline requirements from CMS.
  • Institutes a 90-day reporting period for each year, regardless of stage or program experience
  • Encourages interoperability among EHR systems
  • Expands hardship exemptions, as they are very narrowly defined under current regulations

In the press release, Rep. Ellmers made the following statement:

Today’s legislation is key to supplying healthcare providers with flexibility and certainty, as they struggle yet again to meet the Centers for Medicare & Medicaid Services’ (CMS) stringent requirements pertaining to Meaningful Use. This legislation supplies relief by delaying Stage 3 rulemaking until at least 2017 in order to give providers time to breathe and a reprieve from the unfair penalties.”

“Only 19 percent of providers have met Stage 2 attestation requirements—a clear sign that physicians, hospitals and healthcare providers are challenged in meeting CMS’ onerous requirements. Given this basic fact, I’m uncertain why CMS would continue to push forward with a Stage 3 rule. From my conversations with doctors back home, it is clear they are eager for relief.”

“As a nurse, I can speak to the fact that a patients’ health and safety must be put first. This legislation will ensure that hospitals and providers can effectively share information so they can continue to focus their time and attention to caring for patients.”            

Transitioning to ICD-10-CM
This webinar will provide Part B providers with an overview of ICD-10-CM and will assist you with planning for the mandated ICD-10-CM transition. This session will include testing opportunities and transition stages that will help you prepare your office for the upcoming implementation. Please note: As per the CMS IOM Publication 100-09, Chapter 6, Section 30.1.1, National Government Services cannot make determinations about the proper use of codes for the provider. Questions related to ICD-9-CM and ICD-10-CM are handled by the American Hospital Association’s Coding Clinic. Details about this resource are available at http://www.ahacentraloffice.org.

Sessions are available on:

Pulmonary Function Tests and E&M Visits on the Same Day
From Regina McNally, VP, Socio-Med
Back in February 2015, it was brought to the attention of SME that NGS Medicare was seeking recovery action and offset for pulmonary function test done on the same day as an office visit.  In researching this matter, we found that CMS issued a MedLearn article, SE 1315.  This MLN article has no dates.

This old claims examiner (I) believed that the article is not appropriate for standard medical practice.  A Modifier 25 should not be needed to claim ANY diagnostic test (not a procedure) on the same day as a visit.  I asked CMS if they thought it necessary to use a Modifier 25 on the E&M code when an EKG or a lab test is also billed on the same day as a visit.  The author finds the position outlined in the article unnecessary. In addition, just because the RACs do not understand standard medical practice, is no reason for CMS to change the rule regarding a standard medical practice.

Therefore, I alerted CMS Central Office staff and asked that recovery actions for lack of a modifier 25 should be stopped and the article be rescinded.  As of today, July 28, 2015 we have been informed of the following:


SE1315 – Pulmonary Procedures and Evaluation & Management (E&M) Services

If any physician has been the subject of a recovery action on the basis of SE1315, the practice should file an appeal as soon as possible to get their money back if it was refunded or offset. 

Physician Groups Band Together to Address America’s Opioid Crisis
AMA convened task force engages physicians to curb opioid abuse

The AMA Task Force to Reduce Opioid Abuse announced the first of several national recommendations to address this growing epidemic.

The AMA Task Force to Reduce Opioid Abuse  is comprised of 27 physician organizations including the AMA, MSSNY, American Osteopathic Association, 17 specialty and six other state medical societies  as well as the American Dental Association that are committed to identifying the best practices to combat this public health crisis and move swiftly to implement those practices across the country.

“We have joined together as part of this special Task Force because we collectively believe that it is our responsibility to work together to provide a clear road map that will help bring an end to this public health epidemic,” said AMA Board Chair-Elect Patrice A. Harris, M.D., MA. “We are committed to working long-term on a multi-pronged, comprehensive public health approach to end opioid abuse in America.”

Medical Society of the State of New York President Joseph Maldonado, MD, said, “In an effort to reduce prescription diversion and abuse, New York has already taken the lead on this issue. New York’s physicians play a critical role in the effectiveness of the toughest opioid abuse program in the nation since August of 2013.  We are honored to become part of the AMA Task Force to address this epidemic.”

The AMA has long advocated in support of important initiatives aimed at addressing prescription drug abuse and diversion. This includes continued work with the administration and Congress toward developing balanced approaches to end prescription opioid misuse, as well as supporting congressional and state efforts to modernize and fully fund PDMPs.

The new initiative will seek to significantly enhance physicians’ education on safe, effective and evidence-based prescribing. This includes a new resource web page that houses vital information on PDMPs and their effectiveness for physician practices, as well as, a robust national marketing, social and communications campaign to significantly raise awareness of the steps that physicians can take to combat this epidemic and ensure they are aware of all options available to them for appropriate prescribing.

Diagnosing TBI in Your Office
Hospital data reveal that within New York State, over 550 persons per day sustain a brain injury caused by stroke, a Traumatic Brain Injury (TBI) or other factor(s). Actual incidence is higher as the prior numbers reflect only hospital based data; excluded are persons with brain injuries who seek treatment in a clinic, urgent care, or physician’s office, and those with the injury who are not aware of it.  Even a “mild” brain injury can result in lifelong disability, especially if proper treatment is not received.

To promote recognition and treatment of brain injury, the State University of New York at Albany’s School of Public Health produced a webcast, “Recognizing and Treating Mild Brain Injury” for health practitioners, in collaboration with a Federal grant awarded to the New York State Department of Health. The webcast, via “Public Health Live” received rave reviews from the physician, nurse, and nurse practitioner audience.  The program features the one page, evidenced based TBI diagnostic tool, “Acute Concussion Evaluation” (ACE) available free of charge from the Centers for Disease Control and Injury Prevention (CDC) website.

The goal of the program is to increase the number of practitioners able to recognize even the subtle signs of brain injury which may not surface until weeks even months after the initial trauma. That diagnostic ability can save lives and ameliorate the suffering caused by brain injury. The program is easy to access, and lists brain injury related information and materials, including the link to the ACE, all available free of charge. Continuing Medical Education Credits are available as listed below. Practitioners are encouraged to log on to the training at: http://www.albany.edu/sph/cphce/phl_0415.shtml

Continuing Medical Education Contact Hours: The School of Public Health, University at Albany is accredited by the Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. The School of Public Health, University at Albany designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits TM. Physicians should claim credit commensurate with the extent of their participation in the activity. Continuing education credits will be available until February 2016.

The training was paid in part by a grant from the Health and Human Resources and Services Administration to the NYS Department of Health Grant # H21MC26921.  For more information about the TBI Grant contact, helen.hines@health.ny.gov.


Doctors Digital Agency
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