October 7, 2016 – Should Medicare Negotiate Drug Prices?

Dr. Reid
Dr. Malcolm Reid
October 7, 2016
Volume 16, Number 35


Dear Colleagues:

Our successes at MSSNY are achieved as a result of the combined efforts of many energetic physicians across the State along with the efforts of our talented staff.

Today is the last day of one of our leading staff members, Senior Vice President and Chief Legislative Counsel Elizabeth Dears Kent.  After dedicating 22 years of her professional life to advocating on our behalf, Liz is moving on to an amazing opportunity to be the Governmental Affairs Director for EHR vendor Dr. First.

Her legislative accomplishments for us are enormous, from efforts to enact the Managed Care Bill of Rights in the 1990s, to our most recent successes in providing needed flexibility for physicians in complying with the e-prescribing mandate.  She has been extensively involved in efforts to prevent the enactment of literally hundreds of adverse bills, including bills that would have increased your liability premiums, inappropriately expanded the scope of practice of numerous non-physicians, and have required overbroad and costly state regulation of private physician offices.  She has also helped steer MSSNY through some of the most difficult issues facing our profession, including the transition to value-based payments across public and private payors, and the increased demand for public information regarding the quality of care of physicians and other health care providers.

All physicians across the State of New York owe Liz a big thank you for all of her efforts.

As part of her diligence, Liz trained her successor well, long time MSSNY lobbyist, Morris (Moe) Auster, who ably will take the reins of our Government Affairs division.  We wish Moe the best of luck.  With all the challenges we face, we know he’s got his work cut out for him.

Malcolm Reid, MD, MPP
President, Medical Society of the State of New York

Please send your comments to comments@mssny.org

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If You Have Not Revalidated with Medicaid, You Will Not Be Paid after October 27
Effective for eMedNY claims processing starting October 27, 2016, all claims from non-revalidating billing providers will be pended until the provider’s revalidation package is received. To avoid interruption of claims payment, providers must revalidate immediately.

The federal regulation 42 CFR 455.414 requires providers to revalidate their enrollment with the New York State Medicaid Program. Providers have already received individual written reminders to revalidate, although thousands of providers have not done so. The deadline for submission of revalidation packages was September 25, 2016.

To revalidate:

  1. Visit the Provider Enrollment page at www.emedny.org/revalidation,

locate your enrollment form and additional required documentation, and determine whether an enrollment fee is required. There is a slide presentation, step-by-step processes, and an FAQ section. These resources provide important information on the revalidation process.

  1. Complete and mail the appropriate form(s) with all required documentation to the address provided. Keep a copy of the forms and documentation.

Next steps:

  1. Allow 2 to 3 weeks for the receipt and processing of the revalidation packet by eMedNY.  Once your completed revalidation is received and processed, all claims that have been held due to missing or late revalidation will be released for processing during that cycle.
  2. If more than 3 weeks have passed since sending the revalidation to eMedNY, please contact providerenrollment@health.ny.govwith the subject “FINAL REVALIDATION NOTICE” and provide all pertinent information regarding your submission, such as the date you sent it, and the address you sent it to so that we can research it.
  3. The remittance message for these pended claims is: Health Claim Status Code: 46 INTERNAL REVIEW/AUDIT

If you have additional questions about revalidation, please contact us at providerenrollment@health.ny.gov with the subject “FINAL REVALIDATION NOTICE”, or call the eMedNY Call Center at 800-343-9000 Option 2.

Physicians Required to Comply with “Non-Discrimination” Reporting Provisions by Mid-October
Under new HHS rules implementing the ACA “Nondiscrimination” provision, covered entities (which include most physicians) must post and publish new mandatory nondiscrimination statements and taglines in the 15 most popular languages for the State by October 16, 2016. This is CMS’ list of the top 15 languages spoken in New York: Spanish; Chinese; Russian; French Creole; Korean; Italian; Yiddish; Bengali; Polish; Arabic; French; Urdu;  Tagalog; Greek and Albanian.

To read a comprehensive summary prepared by Donald Moy, Esq. from the firm of MSSNY’s General Counsel, Kern Augustine PC, to assist physicians with compliance, click here.

At this time, MSSNY is exploring some vendors that should be able to help our members deal with real-time translation services to comply with both the LEP (language) and the ADA (hearing impaired/blind) requirements.  Until we have completed our research, you should contact your local hospital since they subscribe to the translation services and the hospital may be able to make a referral for use in your office, at the present time.  As soon as our research is completed, we will get back to you.

KFF Poll: 88% Said Medicare Should Be Able to Negotiate Drug Prices
An overwhelming majority of Americans favor government action to restrain prescription drug prices, according to a poll released by the Kaiser Family Foundation on September 29.

Eighty-two percent of those polled said they want Medicare to negotiate prices with the companies, which Congress does not allow. Seventy-eight percent favored limiting the amount companies can charge for high-cost drugs, such as those that fight cancer or hepatitis, according to the poll from the Kaiser Family Foundation. And more than two-thirds want to let Americans buy drugs imported from Canada. Support is strong no matter the political party. The poll found that while a majority of Americans still believed prescription drugs developed over the past two decades have improved lives, respect is dwindling. In 2008, 73 percent of Americans said the medicines had this positive effect, but that number dropped to 62 percent in August 2015.

The poll found that three-quarters of Americans considered drug costs unreasonable. Despite the perceived burden, the poll also discovered that 73 percent of people taking prescription medicines said it had been easy to afford their drugs. People in fair or poor health and those taking four or more drugs were more likely to say they were having trouble affording prescriptions than more healthy people.

Other ideas were less popular, including two restricting consumers. A minority of those polled favored eliminating prescription drug advertisements, which has been suggested to quell the aggressive marketing companies do directly to consumers. Only 4 in 10 Americans favored requiring people to pay more if they don’t choose the least expensive version of a drug to treat their illness.

The survey was conducted between Sept. 14 and 20 among 1,204 people, using both land lines and cell phones. The margin of error was +/- 3 percent.

Your membership yields results and will continue to do so. When your 2017 invoice arrives, please renew. KEEP MSSNY STRONG!

Reports Show 2017 Medicare Payment Adjustments
As reported in the September 29 AMA Advocacy Update, Medicare has made available two new reports with information on 2015 cost and quality data that indicate which physicians or practices will see related Medicare payment adjustments in 2017.

The 2015 Physician Quality Reporting System (PQRS) Feedback Reports and 2015 Annual Quality and Resource Use Reports (QRUR) were released on September 26, and CMS is mailing letters to physicians beginning September 26 if they will have a penalty.

The payment adjustments detailed in these reports are NOT the result of MACRA legislation passed by Congress in 2015.  They are associated with current federal statutory pay for performance programs that are being replaced in 2019 with the new MIPS system created under MACRA.

2015 PQRS penalty letters notify physicians and groups who are scheduled to receive a 2% penalty in 2017 based on 2015 PQRS reporting. The PQRS feedback report allows physicians to look up whether they will receive the 2% 2017 PQRS penalty, and contains detailed information on program year 2015 PQRS reporting results.

The 2015 Annual QRURs provide information on how practices performed on quality and cost measures used in the Value Modifier (VM) and whether their VM payment adjustment will be positive, negative or neutral and the specific amount. VM penalties can range from -1% to -4% depending on practice size and performance. Bonus payments depend on how much money is collected from penalties and to date the 2017 bonus size has not been publically announced by CMS.

Practices that believe there are errors in the report or calculation of the payment adjustment should file for an informal review by the end of November.

How to access the reports:

  • An Enterprise Identity Management (EIDM) account with the appropriate role is required for participants to obtain 2015 PQRS feedback reports and 2015 Annual QRURs.
  • If you already have an EIDM account, visit the CMS websiteto sign up for the appropriate EIDM role or contact QualityNet Help Desk to determine if someone in the practice already has that role.
  • To sign up for an EIDM account, visit the CMS Enterprise Portaland click “New User Registration” under “Login to CMS Secure Portal.”
  • For more information on viewing the reports, view the PQRS Analysis and Payment webpageand How to Obtain a QRUR webpage.

Information on the informal review process:

  • To request an informal review of a 2017 PQRS negative payment adjustment, view the “2015 Physician Quality Reporting System (PQRS): 2017 Negative Payment Adjustment – Informal Review Made Simple” guide on the PQRS Analysis and Payment webpage.
  • To request an informal review of the 2015 QRURs or the 2017 Value Modifier calculation, see the 2015 QRUR and 2017 Value Modifier webpage.

WCB Proposes a Drug Formulary for Injured Workers
The New York State Workers Compensation Board is inviting public comment on a Discussion Document available from its website that proposes the creation of a Workers Compensation pharmacy benefit plan.

In releasing the Discussion Document the Board noted: “The rapid pace of change in the pharmaceutical industry over the last few years has rendered the Board’s pharmacy benefit structure inadequate to address the overwhelming number of new medications that have been introduced to the medical community. The Board’s current pharmacy benefit describes reimbursement levels for brand, generic and compounded products, but otherwise provides little structure or guidance to prescribers. There is no drug formulary in place; no requirement for pre-approval/prior authorization; no process to ensure the appropriateness of prescribed medications.”

The deadline for receiving comments is November 14.  MSSNY will work with affected specialty societies and groups representing injured workers to review the document and will provide comments as necessary.

MSSNY-Home Care Workgroup Seeks to Reduce Administrative Burdens
As directed at this year’s House of Delegates, MSSNY has established a work group with the Home Care Association of New York State (HCA) to collaborate on efforts to address overbearing administrative burdens that stand in the way of patients receiving, and physicians ordering, needed home care services.  The first meeting of the group took place in September and another is scheduled for the end of October.

One of the most important issues under discussion is how best to reduce the burden of the so-called “Face to Face” requirement included in the ACA.  This provision requires a certifying physician to document that he or she, or a non-physician practitioner (NP or PA) working with the physician, has seen the patient, as a precondition of eligibility for Medicare and Medicaid coverage for home health services.  Many home care agencies and physicians have noted that the CMS regulations implementing this provision have created unnecessary and overly burdensome documentation requirements that are delaying or denying coverage for needed home care services.  One home care provider shared an example of a CMS review agent denying the patient’s coverage for services based on his assessment of the physician’s documentation, despite concurring that the patient met the requisite eligibility criteria and indeed needed the services.

On the federal level, New York Representatives Tom Reed (R-Southern Tier) and Paul Tonko (D-Capital District) initiated a sign on letter to CMS with over 70 other members of Congress to urge simplification of the Face to Face requirement.  Specifically, the letter noted that “the current regulations contain complicated, confusing, and overlapping documentation requirements that exceed the intent of the law passed by Congress. These requirements have imposed a significant burden on home health providers and physicians in our districts”.

On the state level, as the state has now moved (as of July 1) to implement Face-to-Face for Medicaid,  HCA and MSSNY, the Healthcare Association of New York State (HANYS) and the Iroquois Healthcare Alliance have met with the New York DOH to urge mitigation of such an added layer of burden for Medicaid.  These groups have also suggested areas where the Face to Face requirement could be eliminated entirely for Medicaid, such as within the context care delivered under managed care, or other “managed care-like” models, such as within a regional Performing Provider System (PPS) established under DSRIP, or an ACO, health home or other integrated model.

The work group has also discussed the importance of assuring physicians are properly educated regarding these federal requirements, including the importance of completing certification in a timely and comprehensive manner.

MSSNY Representatives for this work group include Dr. Evelyn Dooley-Seidman, Chair of MSSNY’s Long-Term Care Committee; MSSNY Board of Trustees Member Dr. Andrew Kleinman; Dr. Ruth Kleinman; Dr. Eugene Kalmut; and Dr. Jay Slotkin.

To view a brief CMS power point presentation regarding these Face to Face rules, go here.  To read a detailed FAQ document prepared by CMS, go here.

For more information about the activities of the Task Force, please contact mauster@mssny.org.

Most Children Who Contract Zika after Birth Only Fall Mildly Ill, Study Suggests
The New York Times (9/30) reported that a study published in The Lancet Infectious Diseases suggests that “serious complications are rare among children infected with the Zika virus after birth.” Researchers used data reported to the Centers for Disease Control and Prevention since 2015, including “about 160 teenagers and toddlers” aged 1 month to 17 years. In general, “these children got only mildly ill: 129 had a rash, C.D.C. researchers found, while half were feverish and a quarter had red eyes or joint pain.”

AMA: “CMS Listened about MACRA Reporting”
Recently, the AMA saw evidence that CMS has been listening to physician concerns, when CMS Acting Administrator Andrew Slavitt announced that physicians can choose among four options to avoid payment penalties in 2019. Medicine welcomed CMS’ decision to allow physicians to pick their own pace for the initial MACRA reporting period in 2017 as a positive step toward giving all physicians a fair opportunity to succeed.

Although details on MACRA implementation will not be available until the final rule is released later this fall, we have developed a number of resources to help physician practices begin to prepare for the transition to the new payment system:

  • MACRA website – Includes a checklist with steps practices can take now to prepare, an action kit and slideshow with information about what is in the proposed rule, an outline of advocacy efforts, a “Guide to physician-focused payment models,” and additional resources
  • AMA STEPS Forward® module, “Preparing your practice for value-based care – CME-accredited activity provides steps to take, answers to common questions and case vignettes
  • New podcast series “Inside Medicare’s new payment system” (available here) – Produced by ReachMD, these downloadable audio stories feature interviews with industry experts and physician leaders (including CMS’ Andy Slavitt, AMA President Andrew Gurman, MD, and the AMA’s Richard Deem and Michael Tutty)
  • AMA Wire® stories – Ongoing articles on the latest MACRA developments, how physicians are participating in new models of care, and more

The AMA will soon release a new web-based tool to help physicians understand which MACRA pathway is best for them and assess its impact on their practice. The AMA is planning regional seminars on MACRA, as well as webinars for physicians and “train the trainer” webinars.

RFP for Office of Temporary and Disability Assistance


The New York State Office of Temporary and Disability Assistance (OTDA), Division of Disability Determinations is issuing a Request for Proposal (RFP) to solicit proposals from qualified vendors for the establishment of one contract medical provider to establish a site in the upstate area of the Capital District, NY (including the cities of Albany, Schenectady, and Troy and the immediate geographic area) to perform medical examinations and ancillary testing of claimants applying for Social Security disability benefits. If your organization is capable of performing a high volume of medical examinations and diagnostic tests, the Capital District Consultative Examination RFP can be found on the OTDA website at https://otda.ny.gov/contracts/procurement-bid.asp.  If your organization wishes to receive a hard copy of the RFP, please send your request immediately by Certified Mail to:

Mr. Lawrence Rockefeller
NYS Office of Temporary and Disability Assistance
Division of Disability Determinations
One Commerce Plaza, 10th Floor
99 Washington Avenue
Albany, New York 12210

The RFP release date is September 14, 2016 with proposals due no later than November 2, 2016 at 3:00 p.m. EST.  If you have any questions, you may contact Melinda Kuiken at (518) 626-3042.

New Law Reduces Physician Reporting Burdens for Paper Prescriptions
As reported last week, Governor Cuomo has signed into law legislation (S.6779, Hannon)/A.9335,Gottfried) strongly supported and advocated for by MSSNY which eliminates the requirement for a physician to report a litany of information to the New York DOH when he/she must issue a paper prescription in lieu of an e-prescription.  Instead, the new law requires that the physician make a notation in the patient’s medical record that a paper/oral/fax prescription was issued in those circumstances, articulated in the statute, that are excepted from the general e-prescribing requirement.  These circumstances include:

  • Temporary technological or electrical failure;
  • When the prescription will be dispensed by a pharmacy located outside the state;
  • When the physician reasonably determines that an e-prescription would be impractical for the patient to obtain the medication in a timely manner, and such delay would adversely impact the patient’s medical condition.

MSSNY thanks the many physicians across New York who responded to our call to contact their legislators and the Governor to express their support for this legislation.  MSSNY worked closely with the Healthcare Association of New York State (HANYS) and numerous specialty societies to advocate for this important change to the law.

Upon learning that the bill was signed into law, MSSNY President, Malcolm Reid, MD issued the following statement. “We are pleased that Governor Cuomo has signed into law legislation to reduce the reporting burdens in those situations when a physician must issue a paper prescription.  We thank Senator Hannon and Assemblyman Gottfried for championing this legislation.  We look forward to working with the Governor and the Legislature to address other obstacles related to e-prescribing that interfere with patients timely receiving needed medications”.

Millennials Don’t Plan on Getting Flu Shot
 A survey conducted in September by Harris Poll on behalf of CityMD, an urgent-care-center network, found that 52 percent of millennials don’t plan on getting the flu shot during this year’s influenza season. Of those, 49 percent said they don’t trust that the vaccine will prevent them from getting the flu. An additional 29 percent worried that getting the shot will actually make them catch the virus. Citing recent studies, the CDC says the vaccine “reduces the risk of flu illness by about 50 percent to 60 percent.” Last season, 43.6 percent of Americans got the vaccine, according to CDC data.


Elegant Plastic Surgery Office (Upper East Side Manhattan)
Very large and classy office to share. Located in the ground floor of a 25′ x 100′ carriage house opposite the 66th Street Armory with large consult room, 2+ treatment/exam rooms, large waiting room, business office, storage. See video of office — you won’t believe it: www.youtube.com/watch?v=Uli8Cck_eRA   $5000/month incl utilities. no brokers. Call Doctor Fischman at (212) 472–3300.Jeffrey R. Fischman, M.D.  110 E 66th Street.

Well-Established Nassau County Internal Medicine Practice Available for Acquisition
After serving the community for 34 years, this well-established internal medicine practice is available for acquisition. The practice is multi-specialty with significant volume of primary care patients. This office is located in Plainview on a major street with excellent visibility and accessibility, with ample parking. For more information please call (516)822-4706 or E-mail to surendralal1@yahoo.com

Considering Outsourcing Your Billing?
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Physician Opportunities

County Executive
The Suffolk County Medical Society, a 501C-6 corporation, recognized as the premier professional medical association for the physicians of Suffolk County, is seeking to fill the position of Executive Director.  Successful candidates will possess a Bachelor Degree, (Masters Degree preferred in a healthcare-related field and/or Business/Finance).  Should have minimum of five years experience in healthcare or association management .  Must possess the following abilities: have a thorough working knowledge of the health care industry;  serve as a strong physician and patient advocate; be able to successfully balance multiple demands; possess strong leadership skills with excellent oral and written communications.For more information and a complete job description, visit www.scms-sam.org.  Please forward a resume with a cover letter outlining how you meet the parameters of the position, including salary requirements, to stuscms@optonline.net.  Position scheduled to begin February, 2017.

A Private Multidisciplinary Medical Group is seeking an Internal Medicine/Family Medicine Physician in Manhattan
A well-established Manhattan based private multidisciplinary medical group is seeking to hire an Internal Medicine/Family Medicine Physician. This is a great opportunity to start your own practice in a modern office in midtown Manhattan. Attractive base salary plus comprehensive benefits package offered (Malpractice, 3 weeks paid vacation, 1 week CME, CME allowance, paid health insurance, etc).If you are a solo practitioner in private practice looking to join a private group practice, we will work with you to make the transition seamless. Please email your CV to tsrgexpress@gmail.com. No recruiters please.

A Private Multidisciplinary Medical Group is seeking a Podiatrist in Manhattan
A well-established Manhattan based private multidisciplinary medical group is seeking to hire a Podiatrist. This is a great opportunity to start your own practice in a modern office in midtown Manhattan. Attractive base salary plus comprehensive benefits package offered (Malpractice, 3 weeks paid vacation, 1 week CME, CME allowance, paid health insurance, etc).If you are a solo practitioner in private practice looking to join a private group practice, we will work with you to make the transition seamless. Please email your CV to tsrgexpress@gmail.com. No recruiters please.

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