MSSNY eNews: August 21, 2014

 Dr. Joseph R. Maldonado Twitter_logo_blue1
August 21, 2015
Volume 15, Number 32

Dear Colleagues:

This past week, POLITICO reported that non-profit insurers are losing money on the Medicare Advantage products under the ACA.  Essentially, the rising cost of operations, the transitional reinsurance fee and health insurance industry fee have been blamed for company losses.  Whereas national for-profit insurers can better spread their varying regional costs of operations, constraints by the federal government on non-profit regional plans reportedly reduce these regional plans’ abilities to mitigate their losses.  These regional plans are vital as they stimulate competition in regional marketplaces.

Ironically, this summer, we have learned of three for-profit insurers (Anthem, Aetna and Centene) seeking to make acquisitions which will reduce the number of competitors in many markets.  These endeavors to consolidate by national for-profit insurers flies in the face of the ACA endeavor to promote competition.  Clearly, the attempts will test the Department of Justice in regards to upholding and interpreting anti-trust laws.

These merger and buy-out attempts come in the wake of studies that highlight just how anti-competitive the markets really are.  The December 2014 GAO Report on markets revealed that in many states, 80% of the insurance products were controlled by three insurers [GAO, Private Health Insurance, 2014].  The AMA’s 2014 study found in 41% of the metro markets studied, one insurer controlled over 50% of market [AMA, Competition in Health Insurance, 2014].

The challenges faced by the non-profit insurers in regional markets are not trivial.  Given the efforts of for-profit companies to consolidate and further control healthcare markets, it’s becoming difficult to see non-profit insurers providing a sustainable alternative to for-profit insurer products.  If non-profit insurers want to survive, it seems to me that they must recognize the value of incentivizing physicians to par with their product offerings.  Physicians have no vested interest in supporting and promoting monopsony scenarios being advanced by the for-profit insurers.  The more attractive non-profit products become to physicians, the greater the likelihood that physicians will be able to exercise individual choice and  opt out of for-profit, competition-limiting products that may be deemed by the physician to be unfair to physicians and their patients and move into competition promoting non-profit products.

Perhaps it’s time for us to reconsider a statewide IPA which could align with such non-profit payers in New York.  At the same time, we need to ramp up the call for collective negotiations legislation so as to mitigate the monopsony scenario currently fomenting.

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

Please send your comments to


Governor Vetoes Medicaid Managed Care Prior Approval Legislation
Governor Cuomo vetoed legislation (A.7208, Gottfried/S.4893, Hannon) passed by the New York State Legislature that would have strengthened “prescriber prevails” protections in Medicaid managed care when physicians prescribe certain medications to their patients.   In 2012, the Legislature passed a law to assure “prescriber prevails” protection for anti-depressant, anti-psychotic, anti-rejection, epilepsy, seizure, endocrine, hematologist and immunologic medications drug classes similar to the Medicaid fee for service program, but a quirk in the law has given MMC plans the ability to unfairly delay or deny approval, undermining the intent of the law. The bill was seeking to fix the loopholes of this law.

The Governor’s veto message noted that:

“I remain committed to ensuring that patients receive the prescription medication recommended by their treating physicians. Current law already includes critical member protections such as rights of appeal, external appeal and fair hearing.  I have further directed the Department of Health (DOH) to respond promptly when patients or their treating physicians assert that managed care plans are preventing them from accessing their medications.

However, enacting this bill would have a significant and un-budgeted impact on the Medicaid global cap outside of the State’s budget process. This would necessarily impact other Medicaid services that may need to be reduced to accommodate this unanticipated spending. This bill would also limit managed care plans’ efforts to deter and prevent inappropriate utilization, thereby hindering the State’s ability to effectively manage pharmacy programs.  Accordingly, I am constrained to disapprove this bill.”

The bill had been supported by many patient advocacy groups.  MSSNY issued a statement that noted “We are disappointed that the bill was vetoed.  The legislation resulted from the fact that there are many physicians, most particularly psychiatrists, who have reported situations regarding Medicaid managed care plans inappropriately delaying access for medications needed by their patients.  Consistent with the veto message, we will work with specialty societies to bring these complaints to the Department of Health to address these plan abuses.”

In this regard, physicians who have experienced inappropriate delays or denials from Medicaid managed care plans in the above-listed drug classes are encouraged to share this information with MSSNY’s Division of Governmental Affairs so that we can press DOH to investigate the companies perpetrating these prior approval abuses.

Support Schumer-Crowley Legislation to Increase Residency Slots
All physicians and medical students are urged to contact their respective members of Congress in support of legislation to increase the availability of medical residency opportunities to help to address the physician shortage problem we face.  A customizable template letter can be sent from the MSSNY Grassroots Action Center here.

These efforts are part of the third annual “Save GME Action Week” where medical students from across the country will advocate for GME funding protection and expansion using legislator visits, letters, phone calls, and social media.  Their “ask” is twofold: 1) Maintain current funding for GME; and 2) Support legislation that will expand GME funding sources and the number of residency positions. MSSNY together with AMA strongly supports legislation introduced in Congress, the Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/S. 1148), sponsored by New York’s Representative Joseph Crowley and Senator Charles Schumer, to create 15,000 new residency slots to overcome the outdated cap placed in 1997.  The AMA has also created a designated advocacy page in support of these efforts, entitled

E-Prescribing Of All Substances Required By March 27, 2016
Physicians and other prescribers are reminded that New York State’s e-prescribing requirements for non-controlled and controlled substances will go into effect on March 27, 2016. The NYS Department of Health’s Bureau of Narcotic Enforcement has provided information to physicians and other prescribers to assist them in their transition to electronic prescribing.   Practitioners should continue their efforts to become compliant with the law, including working with their software vendors to implement the additional security requirements needed for e-prescribing of controlled substances (EPCS), and registering their certified software applications with the Bureau of Narcotic Enforcement.   According to state officials, over 22,000 prescribers have registered their systems with DOH.

For physicians who prescribe controlled substances, there are additional steps to complete in order to electronically prescribe controlled substances.  These include the following:

  • First, the software you currently use must meet all the federal security requirements for EPCS, which can be found on the Drug Enforcement Agency’s (DEA) web page.

Note that federal security requirements include a third party audit or DEA certification of the software.

  • Second, you must complete the identity proofing process as defined in the federal requirements.
  • Third, you must obtain a two-factor authentication as defined in the federal requirements.
  • Fourth, you must register your DEA certified EPCS software with the Bureau of Narcotic Enforcement (BNE). Registration instructions are included in the FAQs.

A copy of the BNE’s Frequently Asked Questions (FAQs) can be found here.

EPCS systems must be registered through the ROPES system.  ROPES stands for: Registration for Official Prescriptions and E-Prescribing Systems. To access ROPES, use the following steps:

  • Login to the Health Commerce System (HCS) at
  • Under “My Content” click on “All Applications”
  •  Click on “R”
  •  Scroll down to ROPES and double click to open the application. You may also click on the “+” sign to add the application “ROPES” under “My Applications” on the left side of the screen.

EPCS became permissible in New York State and over 90% of the pharmacies can now accept e-prescribing for controlled substances, according to officials from BNE.

DrFirst and MSSNY have partnered to bring MSSNY members the industry’s leading e-prescribing solution at a special discounted price. Information on this program can be found here.

There are additional venders that now have software available to e-prescribe both non-controlled and controlled substances and information on these can be found here.

There will be a waiver process for those physicians who experience technological or financial issues, however, DOH has not yet released this process, but it is expected to do so before January 1. The waiver process will be electronic.   Waivers will be provided for a facility, a large medical practice or an individual physician. The law provides that physicians may apply for a waiver of this e-prescribing requirement as a result of a) economic hardship b) technological limitations that are not reasonably within the control of the physician, or c) other exceptional circumstance.  DOH has indicated that more information on the waiver process will be available shortly.

E-prescribing of non-controlled substances is also required under the law; however, registering of this system with the state is not necessary.

The ISTOP legislation enacted in 2012 required e-prescribing of ALL substances. Regulations pertaining to the E-prescribing requirements were adopted on March 27, 2013.   The Medical Society of the State of New York was successful in obtaining a delay in the e-prescribing requirements for all substances until March 27, 2016.

Information regarding e-prescribing may be accessed at the following links: 

AMA Foundation Presents MSSNY/Dr. Duane and Joyce Cady Scholarships
This week, the AMA Foundation presented 27  Physicians of Tomorrow scholarships, including the MSSNY/Dr. Duane and Joyce Cady Honor fund, which will provide $10,000 scholarships to fourth-year medical students. “It was a dream come true,” said Duane M. Cady, MD, the namesake of the New York honor fund and scholarships. “I only wish we could do more, especially after seeing the financial needs of the students.”

Visit the AMA Foundation website next week to view the recipient listing and biographies and learn more about the 16 honor funds.

The AMA Foundation has made it a priority to assist medical students in handling the rising cost of medical education. The Physicians of Tomorrow Awards were created in 2004 to provide financial assistance to medical students facing spiraling medical school debt. On average, medical students in the U.S. graduate with a debt load of nearly $162,000. A large debt burden may deter many from practicing in underserved areas of the country or practicing primary care medicine. To date, over 1 million has been granted to exceptional medical students across the nation.

Insurers, PBMs Consider Whether To Cover Female Libido Treatment
Bloomberg News (8/20, Edney) reports that following FDA approval, “health insurers are grappling with the question of whether to cover” Sprout Pharmaceuticals’ Addyi (flibanserin), which treats low libido in women but will have a “prominent warning label for serious side effects.”  Anthem Inc. announced Wednesday that it would cover the drug in many cases, while Cigna Corp. and Aetna Inc. are still working on their policies. PBMs Express Scripts Holding Co. and CVS Health Corp. say they are in the process of evaluating the drug.

USA Today (8/20, Ungar) reports that “it’s still unclear whether and how insurers will cover” the new treatment. Sprout Pharmaceuticals CEO Cindy Whitehead says she expects “parity coverage” from insurers between Addyi and erectile dysfunction drugs, adding that out-of-pocket costs should be similar as well. Analysts note that while PBMs are “aggressively narrowing formularies,” there could be a public outcry if insurers and employers decline to cover the drug, especially if male sexual health treatments are covered. 

STEPS Forward Initiative to Help Physicians Combat Burnout
The problem of burnout and caregiver fatigue among physicians is real and immediate. In fact, research shows that the rates of overall burnout extend to about 40 percent of U.S. physicians, more than 10 percentage points higher than the general population. In response, the AMA has created a program aimed at successfully preventing burnout and promoting well-being for medical professionals.

AMA STEPS Forward, the online practice transformation series launched last June, is offering new online modules that help physicians learn their risk factors for burnout and adopt real-life strategies to reignite professional fulfillment and resilience.

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

Members Only: Your Patients Can Save Up to 75% on Prescriptions
With the rising cost of generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% on your prescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact for your cards!

August 26th Webinar on The Veterans Choice Program
Hear from leading Veterans Administration officials on new community-based care options, collectively referred to as the Veterans’ Choice Program, for VA beneficiaries in an AMA-hosted Webinar on August 26 from 7pm-8pm.  The AMA successfully advocated for these options to be included in the Veterans Choice and Accountability Act of 2014 to help address staffing shortages at the VA that were uncovered during last year’s scandal.

By explaining how non-VA providers can sign-up to deliver care through the Veterans Choice Program, this webinar will explain how the VA is relying on private practitioners as a short-term solution to delivery problems and workforce shortages.  Participants will understand the conditions of participation and learn how to troubleshoot claims processing issues and payment delays.  The webinar will also dispel common misconceptions about the Choice Program and the presenters will conclude with an assessment of ongoing policy challenges.  Physicians can register for the webinar here.

From Workers Compensation Re September District Dialogue Sessions
Thank you to all who attended our Summer BPR Roadshows, which took place during our normal Summer District Dialogue Sessions.  We are very fortunate for everyone’s participation and contribution, making our Summer BPR Roadshow a great success!

Please join us for our Fall 2015 District Dialogue Session.  This will be the Board’s fifth District Dialogue Session since we began holding these sessions in September 2014.  The Board plans to provide those who attend with:

  • The latest update on BPR initiatives.
  • Participant Dialogue Session – time for the Board to hear and discuss topics of interest to you.

We hope you join us at one of our District Offices.  The locations, dates and times are as follows:

  • Hauppauge
    9/1/15, 12-1 PM
    220 East Rabro Drive, Suite 100
    Hauppauge, NY 11788
    Room 116-H
  • Queens
    9/2/15, 12-1 PM
    168-46 91st Ave
    Jamaica, NY 11432
    3rd Floor, Room 325
  • White Plains
    9/3/15, 12-1 PM
    75 S Broadway
    White Plains, NY 10601
    Waiting Room
  • Buffalo
    9/8/15, 12-1 PM
    Ellicott Square Building
    295 Main Street
    Buffalo, NY 14203
    Suite 400, Room 438
  • Rochester
    9/9/15, 12-1 PM
    130 Main Street West
    Rochester, NY 14614
    Basement Conference Room
  • Albany
    9/15/15, 12-1 PM
    100 Broadway
    Menands, NY 12204
    Room 518A & 518B
  • Syracuse
    9/16/15, 12-1 PM
    935 James St
    Syracuse, NY 13203
    1st Floor-General Assembly
  • Binghamton
    9/17/15, 12-1 PM
    State Office Building
    44 Hawley Street
    Binghamton, NY 13901
    18th Floor-Warren Anderson Community Room
  • Brooklyn
    9/22/15, 12-1 PM
    111 Livingston Street
    Brooklyn, NY 11201
    22nd Floor, Room 1917
  • Manhattan
    9/23/15, 12-1 PM
    215 West 125th Street
    New York, NY 10027
    Room 511

The Board has recently added a new email subscription topic for you called “District Dialogues”. Please subscribe to the District Dialogues topic in order to receive any information about past, present, or future District Dialogue sessions. (Click “Manage Preferences” at the bottom left of this email > sign in with your email > click “add subscriptions” > select “District Dialogues” under the General category.) Contact if you need assistance with subscribing.



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