September 8, 2017 – Insurers Act BADLY!

PRESIDENT’S MESSAGE Charles Rothberg, MD

September 8, 2017 Volume 17 Number 34

Dear Colleagues:

I need to inform you of recent adverse activities on the part of a few insurers.

Emblem Health appears to have begun notifying a number of participating physicians that they will no longer be in network effective Jan 1, 2018. This is reminiscent of a campaign two years ago, when approximately 700 physicians were not renewed in an apparent attempt to narrow Emblem’s networks.   In its recent letter, Emblem explained to physicians that this non-renewal was not related to quality or performance issues and need not be reported to credentialing bodies.

A few physicians have filed appeals with the company for re-consideration of their non-renewal status. Presently, one physician had his status overturned and will remain “in network” after
January 1.

Some physicians, already renewed by Emblem’s Medicare Advantage plan, still face uncertainty regarding their Emblem Health commercial line participation.

On an unrelated insurance issue, I was made aware that Anthem health, parent of Empire Blue Cross plans in New York, have been improperly collecting personal identifying information belonging to practice employees – including Social Security numbers, birth dates, and home addresses – in conjunction with the Empire Provider Application.

In this matter, Anthem staff appear to have misapplied 42CFR 455.104. that pertains to disclosure requirements for entities that bill various plans for federal funds— such as Medicare and Medicaid.  Individual solo-practices and some physician group practices are specifically excluded from the necessity to disclose a staff member’s personal information.

As a result of a conference call between MSSNY and Anthem, the insurer agreed to revise its application forms and data collection process.   I anticipate that in short time, they will produce an amended Empire Provider Enrollment Application and that they will properly discard any improperly collected information.  In the meantime, physicians in solo and small practices should be aware that the submission of this information is not required.

MSSNY also continues to seek legislation (A.2704/S.3943 – passed the Assembly this year, but not the Senate) that would require health plans to provide physicians with appropriate due process protections before they non-renew a physician’s contract.  You can send a prepared letter to your Senator by visiting MSSNY’s Grassroots Action Center today.

Late Breaking Response to MSSNY from Emblem Health:
“We continuously review our network as it relates to our membership and to reflect our partnerships in value-base arrangements. We emphasize that this change in our network impacted less than .05% of the physicians within our network. Emblem also recommends physicians who received a non-renewal notice have the option to appeal the decision relating to their Medicare agreement.”

For further information, please call VP of Socio-Medical Economics Regina McNally at 561-488-6100 ext. 334.

Sincerely,
Charles Rothberg, MD
MSSNY President

Please send your comments to comments@mssny.org

Top New York Court Rejects Right to Physician-Assisted Suicide
On September 7, the New York Court of Appeals ruled that physician-assisted suicide is not a fundamental right, and that it would not block the New York Legislature from passing legislation banning physician-assisted death. Physician-assisted suicide is illegal in most states, but in recent years, Colorado, California, Oregon, Vermont, Washington, and the District of Columbia have approved legislation allowing people to request life-ending medication from physicians. No state court, however, has recognized assisted suicide as a fundamental right. (Wall Street Journa l9/7)

The case was brought by three people with terminal illnesses. Two have since died. The plaintiffs had argued that the state’s existing ban on assisting a suicide should not apply to those seeking merciful ends to incurable illnesses.The court disagreed, noting that while state law allows terminally ill patients to decline life-sustaining medical assistance, it does not allow anyone to assist in ending patients’ lives. “The assisted suicide statutes apply to anyone who assists an attempted or completed suicide,” the court wrote in its unanimous decision. “There are no exceptions.”

In their lawsuit, the plaintiffs argued that New York’s prohibition on assisted suicide violated guarantees of equal protection under the law. They alleged the law unlawfully discriminates between terminally ill patients who have the option of dying by declining life-sustaining medical assistance and other terminally ill patients who are unable to hasten their deaths simply by rejecting medical assistance.

MSSNY’s Bioethics Committee is working on an Aid to Dying survey to gather New York physicians’ positions on this topic.

Gov. Reduces Health Insurance Barriers to Substance Abuse Treatment Coverage
New York Governor Andrew Cuomo announced new regulatory guidance this week to better assure New Yorkers can more readily overcome insurance coverage barriers to receiving medications necessary to treat a substance abuse disorder. It was part of a series of initiatives announced this week by the Governor to facilitate new addiction treatment, recovery and support services to residents suffering from substance use disorders in underserved communities throughout New York City and Long Island.

Specifically, a new regulation was issued by the New York Department of Financial Services (DFS) that will require insurers who offer large group coverage to allow consumers to appeal coverage denials for medically necessary addiction medications when they are not on the list of covered drugs.

The regulation calls for an insurer to notify the patient and the prescribing physician within 72 hours of the request and provide coverage of the non-formulary medication for the detoxification or maintenance treatment of a substance use disorder for the duration of the prescription, including refills.  Furthermore, the regulation requires an expedited appeal process for “exigent circumstances” where notification of the determination must be provided to the patient and the prescribing physician no later than 24 hours following receipt of the request.

Moreover, DFS issued a “circular letter”  to New York insurers designed to eliminate impediments to addiction services coverage, “to prevent insurers from excessively reviewing the medical necessity of opioid treatment, and to bar the inappropriate delay of coverage.”

MSSNY Attends DOH: Future of Integrated Care in New York State Workgroup
In 2016, the NYS Department of Health announced that the Fully-Integrated Duals Advantage (FIDA) program received federal approval to be extended until the end of 2019.  The FIDA program is designed to provide managed care coverage to individuals covered by both Medicare and Medicaid.  In response, the DOH workgroup on the Future of Integrated Care in New York State has committed to mapping out a strategy that would help New York State reach its objectives of increasing integration of services, providers, payments, and delivery systems.

The planning committee kicked-off in July where the NYSDOH and CMS presented on the value of integrating Medicare and Medicaid services while sharing insights into models that other states have found success in using. This week’s workgroup focused on target populations, covered services, care coordination/management elements, and assessment and service planning requirements. The Future of Integrated Care in New York State workgroup series will continue on with three additional meetings over the fall in which MSSNY will continue to participate and provide critical input.

Topics to be discussed in these future meetings include network adequacy, payment and rate considerations, and geographic scope.  For more information on the FIDA program, click here.

Promo Code: MSSNY

Addiction Medicine Track Offered at ASAP Conference on September 17, 2017
The New York State Office of Alcoholism and Substance Abuse Services (NYS OASAS) and the Alcoholism and Substance Abuse Providers of New York State (ASAP) is now offering the Addiction Medicine Track at a September 17, 2018 conference.

The conference begins on Sunday September 17, 2017 and finishes on Monday September 18, 2017 and is being held at the Buffalo Niagara Convention Center in Buffalo, New York, near Niagara Falls.  The ASAP conference runs concurrently and will actually finish on Wednesday September 20, 2017 for those who may wish to register for and stay for that.  To register for this program please click here.
This conference track is appropriate for physicians, nurse practitioners, physician assistants and any other staff who may find the material interesting or relevant.  This live activity, Addiction Medicine Track at ASAP’s 18th Annual Conference: Building Bridges, with a beginning date of 09/17/2017, has been reviewed and is acceptable for up to 15.00 prescribed credit(s).

Your membership yields results and will continue to do so. When your 2018 invoice arrives, please renew. KEEP MSSNY STRONG!

Texas Medical Society: Physicians Helping Physicians
The Texas Medical Foundation is soliciting funds to use for grants to help reestablish the delivery of patient care in physician practices in federally designated disaster areas damaged by Hurricane Harvey.

The program will help cover expenses (not covered by insurance or other sources of funding) for relocating or rehabilitating a physician’s medical office. This may include replacing equipment, aiding needed staff, rebuilding patient records, and other similar needs all towards the goal of helping affected physicians once again begin treating their patients. https://www.texmed.org/Harvey

For Members Only: Brooks Brothers Offers 15% Discount
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MSSNY President to Be Honored at Harvest Moon Ball in Glen Cove
MSSNY President Charles N. Rothberg is being honored at the Brookhaven Hospital Harvest Moon Ball at the Nassau Country Club in Glen Cove (Long Island) on Saturday, October 14, 2017 from 6PM to 10PM. Dr. Rothberg will be receiving the Dr. Jacob Dranitzke Award.  For tickets, to donate or be a sponsor, please go here.

Sept. 15: 2017 MSSNY Continuing Medical Education Provider Conference
To meet the challenges facing planners, providers and participants of CME, MSSNY recognizes the need for ongoing education and training of its Accredited Providers as well as physicians and other healthcare professionals in NYS.
The conference will take place on Friday, September 15, 2017, at the Westbury Marriott.  The program is scheduled from 7:30 AM to 3:45 PM.

This conference will inspire participants to explore and interactively address challenges such as self-directed learning for physicians and compliance with the changing accreditation criteria that clearly address practice gaps and practice-based needs while creating opportunities for measurable change in physicians and reinforcing the undeniable link between a successful CME activity and quality improvement for physicians and patients alike.

Registration links and more information are available here.  Featured speakers include Steve Singer, PhD; Vice President of Education and Outreach, Accreditation Council for Continuing Medical Education (ACCME) and Mary Kelly, Project Administrator, AMA PRA Standards and Policy.  MSSNY President Charles Rothberg, MD will deliver the welcome and opening remarks. For more information, please contact Miriam Hardin at mhardin@mssny.org. More information.

Oct. 10-14: Free Vets Health Care Training Program Conference in Niagara Falls
The Medical Society of the State of New York, the New York State Psychiatric Association, and the National Association of Social Workers – New York State Chapter are hosting a two- day conference on
Friday, 10/13 Saturday,10/14 at the Niagara Falls Conference Center, 101 Old Falls St, Niagara Falls, NY. The conference will consist of interactive seminars and panel discussions focusing on the current and evolving healthcare needs of veterans.

MSSNY and NYSPA will be conducting three CME accredited trainings for primary care physicians and specialists. The CME programs are “Invisible Wounds of War: PTSD, TBI & Combat-Related Mental Health Issues,” “Recognition, Management and Prevention of Veteran Suicide,” and “Substance Use Disorders among Returning Veterans.”

There is no cost, but separate registration will be required for both the trainings and conference. More information will be coming shortly.

Dr. Jerome Adams Sworn in As US Surgeon General
The new Surgeon General of the US, Jerome Adams, an anesthesiologist with a master’s degree in public health, was sworn in on Tuesday, September 5.  Dr. Adams previously served as Indiana’s health commissioner.

At the ceremony Tuesday afternoon, Dr. Adams said his motto as surgeon general will be to create “better health through better partnerships” in an effort to address wide-ranging health issues, such as the opioid epidemic, mental health and childhood obesity. He said that law and healthcare must work together to tackle the opioid fight.

Vice President Pence praised Dr. Adams for his work on cutting Indiana’s infant mortality rate, addressing Ebola and helping curb an HIV outbreak stemming from injection drug use. Dr. Adams said that he is eager to start helping victims of Hurricane Harvey as the “nation’s doctor” and reaffirmed his commitment to “letting the science lead him to facilitating locally-led solutions to difficult health problems.”

Plant-Based Diet As Effective As PPIs in Treating Laryngopharyngeal Reflux
Findings published online in JAMA Otolaryngology-Head & Neck Surgery reports that “a plant-based diet is just as effective as proton pump inhibitors in treating laryngopharyngeal reflux,” researchers found in a six-week study involving “85 patients with an average age of 60 treated with the P.P.I.s Nexium [esomeprazole magnesium] and Dexilant [dexlansoprazole], and 99 treated with alkaline water and the Mediterranean diet, a regimen low in meat and dairy, and rich in olive oil, nuts, fish, beans, fruits and vegetables.”

Garfunkel Wild Hosting 4^th Annual Ambulatory Surgery Center Symposium
Garfunkel Wild will be hosting its 4th Annual Ambulatory Surgery Center Symposium on October 20, 2017 at the Crowne Plaza Times Square.  Speakers include representatives from major managed care organizations, CMS, state and national ASC association leaders, hospitals and management company executives, leading consultants and many more. To register or for more information, visit www.nymetroasc.com or call 516-393-2294.

According to CDC Stats, One in Three Americans Are Obese
The Trust for America’s Health and the Robert Wood Johnson Foundation released a report based on statistics from the Centers for Disease Control and Prevention that showed
one in three American adults and one in six children to be obese. The highest obesity rates are found in West Virginia, Mississippi, Alabama, and Arkansas, although the rates of increase in some states may be stabilizing. Trust for America’s Health President and CEO John Auerbach commented, “The adult rates are showing signs of leveling off and the childhood rates are stabilizing. In our review of the policies and strategies, we found that many (states) show a lot of promise for reversing the trends and improving health if we make them a higher priority.”

The data compiled from the Behavioral Risk Factor Surveillance System, relies on self-reported weight data, “so it likely underestimates true rates.” Despite state obesity statistics leveling off, the data indicates that the nation is “at risk of poor health” if programs to address obesity lose funding, according to the Trust for America’s Health CEO.

District Court: Govt. “All But Ignored” Calls for Insurer Payment Transparency
The US District Court for the District of Columbia has ruled on a motion filed by the American College of Emergency Physicians (ACEP) in regard to its lawsuit against the federal government (ACEP v. Thomas E. Price, MD) that argued a regulation under the Affordable Care Act (ACA) violated Congressional intent.
“This is a clear step in the right direction,” said Rebecca Parker, MD, president of ACEP. “It does not invalidate the federal regulation, but
it supports ACEP’s contention that the federal agencies ignored significant concerns raised by public commenters regarding a lack of transparency by health insurance companies in determining payments. Congress in the ACA required that reasonable amounts be paid for emergency care, based on an objective standard, when patients receive it outside of a qualified health plan’s network.”

The court remanded the case back to HHS for further explanation, saying that comments during the regulation’s development had been submitted to CMS expressing concerns “for example, that the methods it used to set payments were not transparent and could be manipulated by insurers…The Departments all but ignored these comments and proposals.”

ACEP originally filed suit in May 2016 against then-Secretary Burwell after the federal government did not address the concerns raised to CMS about out-of-network emergency physician payments, which the agency set at the “greatest of three” options: (1) Medicare (which often does not even cover providers’ costs) (2) In-network rates (set without the provider’s input) (3) “Usual and customary” (as determined by the health plans).  As written, this regulation opened the door for insurers to use non-transparent (“black box”) methods to determine these “usual and customary” payment amounts without providing any means to externally verify the data.

CMS Poster for Coding Information for Preventive Services
https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html