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CMS Proposes Significant Changes to the 2016 Medicare Physician Fee Schedule, including to Stark

August 16, 2015 Leave a comment

CMS Factsheet:

“On July 08, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that updates payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2016. This year, CMS is proposing a number of new policies, including several that are a result of recently enacted legislation. The rule also finalizes changes to several of the quality reporting initiatives that are associated with PFS payments, including the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier (Value Modifier), and the Medicare Electronic Health Record (EHR) Incentive Program, as well as changes to the Physician Compare website on Medicare.gov.”

The proposed rule includes provisions relating to the following;

  • physician quality reporting system
  • “Physician Compare”
  • EHR incentive program
  • Medicare shared savings
  • advance care planning
  • payment provisions on Part B drugs, misvalued codes, RVU reductions, “incident to” services, physician value-based payment modifier, etc.

Perhaps most significant in the area of healthcare business transactions are the physician self-referral (Stark law) updates:

  • expansion of recruitment and retention provisions to NPPs
  • updating physician-owned hospital requirements
  • reducing burdens of technical noncompliance through more reasonable regulations in a number of areas (based on information learned from self-dsiclosures and the rersults of recent cases)

The complete proposed rule as published in the Federal Register on July 15 can be found here.

Comments will be accepted by CMS on the proposed rule until September 8, 2015.

Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care — NEJM

February 1, 2015 Leave a comment

Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care — NEJM

This article (reproduced in full below) in the New England Journal of Medicine, online January 26, 2015,  is by Sylva M. Burwell, Secretary of Health and Human Services.  It discusses the important concepts of efficiency, quality, waste, and rationing and their intersection with the delivery of healthcare.  References can be found at the online article.

* * * * * * * *

Now that the Affordable Care Act (ACA) has expanded health care coverage and made it affordable to many more Americans, we have the opportunity to shape the way care is delivered and improve the quality of care systemwide, while helping to reduce the growth of health care costs. Many efforts have already been initiated on these fronts, leveraging the ACA’s new tools. The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment models; changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and harnessing the power of information to improve care for patients.

As we work to build a health care system that delivers better care, that is smarter about how dollars are spent, and that makes people healthier, we are identifying metrics for managing and tracking our progress. A majority of Medicare fee-for-service payments already have a link to quality or value. Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018. Alternative payment models include accountable care organizations (ACOs) and bundled-payment arrangements under which health care providers are accountable for the quality and cost of the care they deliver to patients. This is the first time in the history of the program that explicit goals for alternative payment models and value-based payments have been set for Medicare. Changes assessed by these metrics will mark our progress in the near term, and we are engaging state Medicaid programs and private payers in efforts to make further progress toward value-based payment throughout the health care system. Through Healthy People 2020 and other initiatives, we will also track outcome measures that reflect changes in Americans’ health and health care.

To drive progress, we are focusing on three strategies. The first is incentives: a major thrust of our efforts is to create an environment in which hospitals, physicians, and other providers are rewarded for delivering high-quality health care and have the resources and flexibility they need to do so. The ACA creates a number of new institutions and payment arrangements intended to drive the health care system in this direction. These include alternative payment models such as ACOs, advanced primary care medical-home models, new models of bundling payments for episodes of care, and demonstration projects in integrated care for beneficiaries dually eligible for Medicare and Medicaid.

Looking ahead, we plan to develop and test new payment models for specialty care, starting with oncology care, and institute payments to providers for care coordination for patients with chronic conditions. Three years ago, Medicare made almost no payments through these alternative payment models,1 but today such payments represent approximately 20% of Medicare payments to providers, and as noted above, we aim to increase this percentage. As part of this work, we also recognize the need to continue to reach consensus on the quality measures used and address issues related to risk adjustment in these new models.

Second, improving the way care is delivered is central to our reform efforts. We have put in place policies to encourage greater integration within practice sites, greater coordination among providers, and greater attention to population health. Through the Partnership for Patients, we have engaged U.S. hospitals in learning networks to focus on high-priority risks to patient safety and have already seen significant improvement. There is now a national program to reduce hospital readmissions within 30 days after discharge, which encourages hospitals to improve transitional care and coordinate more effectively with ambulatory care providers. Readmission rates are decreasing nationwide.2 Through the Transforming Clinical Practice Initiative, we will invest up to $800 million in providing hands-on support to 150,000 physicians and other clinicians for developing the skills and tools needed to improve care delivery and transition to alternative payment models. New Medicaid health homes, patient-centered medical homes, and efforts to reorganize care for people eligible for both Medicare and Medicaid are all designed to foster greater integration and coordination.

Third, we aim to accelerate the availability of information to guide decision making. The Obama administration has led a major initiative in health information technology (IT), focusing on the adoption of electronic health records (EHRs) and their meaningful use as a central avenue for transforming care. The proportion of U.S. physicians using EHRs increased from 18% to 78% between 2001 and 2013, and 94% of hospitals now report use of certified EHRs.3 Ongoing efforts will advance interoperability through the alignment of health IT standards and practices with payment policy so that patients’ records are available when needed at the point of care to permit informed clinical decisions to be made in a timely fashion.  HHS has made a commitment to enhancing transparency in the health care market. For example, the Medicare website enables consumers to compare data on the costs and charges for hundreds of inpatient, outpatient, and physician services. Information is available on the quality of hospitals, physicians, nursing homes, and other providers, enabling consumers to make better-informed choices when selecting providers and health plans.

The ACA established the Patient-Centered Outcomes Research Institute (PCORI), dedicated to generating information that can guide doctors, other caregivers, and patients as they address important clinical decisions; PCORI is working with the Agency for Healthcare Research and Quality to disseminate this information. In the years ahead, the research findings from PCORI, disseminated in part through EHRs, can bring critical clinical information to providers and patients when they need it most, at the point of care.

Although we have much to celebrate regarding increased access and quality and reduced cost growth, much of the hard work of improving our health care system lies ahead of us. Care delivered in hospitals was much safer in 2013 than it was in 2010: there were 1.3 million fewer adverse events between 2011 and 2013 than there would have been if the rate of such events had remained unchanged, and an estimated 50,000 deaths were averted. Still, far too many hospitalized patients — nearly 1 in 10 — have adverse events while hospitalized, and many people do not receive care that they should receive, while others receive care that does not benefit them. Growth of health care spending is at historic lows: Medicare spending per beneficiary increased by approximately 2% per year from 2010 to 2014 — a rate far below both historical averages and the growth rate of the gross domestic product.4 Survey data show that more than 7 in 10 people who signed up for insurance in the new health insurance marketplace last year say the quality of their coverage is excellent or good.5 However, it will take additional effort to sustain and augment the positive changes we have seen so far.

We are dedicated to using incentives for higher-value care, fostering greater integration and coordination of care and attention to population health, and providing access to information that can enable clinicians and patients to make better-informed choices. We believe that, by working in partnership across the public and private sectors, we can accelerate these improvements and integrate them into the fabric of the U.S. health system.

CMS Leaves its Finger in the Dike by Extending its Temporary Moratoria on Enrollment

February 1, 2015 Leave a comment

On January 29, CMS announced last week that it would extend the “temporary moratoria on the enrollment of new ambulance suppliers and home health agencies (HHAs) in specific locations within designated metropolitan areas in Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey to prevent and combat fraud, waste, and abuse.”  The Federal Register will publish this announcement on February 2, 2015.

The ACA allows the HHS Secretary to impose a temporary moratorium on the enrollment of new Medicare, Medicaid or CHIP providers and suppliers to prevent (or combat) fraud, abuse, or waste.  The moratorium is for six months and can be extended in 6-month increments.

The war on healthcare fraud is a lot like fighting roaches in Florida.  You can be very vigilant, keep a clean house, and use pesticide regularly, but there will always be roaches — bigger and stronger ones to replace the ones you kill.  Likewise, we spend lots of money and devote significant resources to fighting healthcare fraud, and no matter how many fraud mongers we put out of business, there are always more to take their places.

The dike has to many leaks.  One wonders how much more legitimate healthcare could be given if so much wasn’t siphoned off by bad guys, but is there a practical solution?

CMS launches database of manufacturer and GPO payments to physicians

October 3, 2014 Leave a comment

The following post will also be published today on the Akerman Health Rx blog.

The Affordable Care Act contains a provision known as the Physician Payments Sunshine Act, which requires the Centers for Medicare and Medicaid Services (“CMS”) to establish a national databank containing information on the financial relationships between physicians (which includes dentists, chiropractors, and other physician specialties) and teaching hospitals, applicable manufacturers, and group purchasing organizations (“GPOs”).  CMS launched its Open Payments website on September 30, 2014 , making its database available to the public.

The database is populated by information reported to CMS by applicable manufacturers and GPOs regarding their payments or other transfers of value to physicians and teaching hospitals.  It is important to note that this reported information specifically includes any ownership or investment interest that physicians (and their immediate family members) have in the manufacturers and GPOs.

CMS encourages physicians and teaching hospitals to register with the Open Payments website.  While registration is voluntary, the reported information is made available to registrants before being made public, and registrants are given an opportunity to dispute any reported information.  In fact, there is a mobile app (and other resources) that allows physicians, teaching hospitals, manufacturers, and GPOs to track provider and industry contact details, share information, and track payments and other transfers of value.

According to CMS and as reported, 4.4 Million payments valued at nearly $3.5 billion were made to 546,000 individual physicians and 1,360 teaching hospitals in the last five months of 2013.  The website will provide future reports on an annual basis.  Beginning in June 2015, it is expected to report twelve full months of data.

We know that the public, and in particular the press, will access the Open Payments database, and there will likely be a high level of misunderstanding and misinformation.  One cannot forget the feeding frenzy that arose when CMS released physician Medicare billing data  earlier this year.  Any physician who receives payments from a manufacturer or GPO would presumably want advance notice of any disclosure regarding payments to that physician.   Accordingly, any physician who does receive such payments should register on the Open Payments website and check the accuracy of all information reported about them, and be prepared to answer questions they may be asked.

Florida Medicaid Managed Care Receives Green Light From HHS

February 8, 2013 Leave a comment

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From Akerman’s Health Law Rx Blog:

POSTED BY SHERYL D. ROSEN AND BRUCE D. PLATT ON FEBRUARY 6, 2013

Florida has been working on a plan to shift the state’s Medicaid population into managed care for nearly two years – ever since the Florida Legislature directed the change in 2011. On Monday the state received the approval it needed from the federal government.

By letter dated February 1, 2013, the U.S. Department of Health and Human Services granted Florida’s request to waive certain provisions of the Social Security Act, allowing the state to transfer some Medicaid recipients from the traditional fee-for-service program into a Medicaid managed care plan for individuals needing long-term care.

The federal waiver is limited to the state’s Medicaid Long-Term Care Managed Care recipients.  It will allow up to 36,795 Medicaid recipients to receive long-term care services from health maintenance organizations (“HMOs”) or provider services networks (“PSNs”) in the recipient’s local area.  Such a transition would include access to services including adult day health care and case management, instead of more costly nursing home care.  The waiver goes into effect on July 1, 2013, ahead of the state implementation deadline of October 1, 2013.  On January 15, the Florida Agency for Health Care Administration (“AHCA”) posted notices of intent to award Medicaid Long-Term Care Managed Care contracts to PSN American Eldercare and HMOs including UnitedHealthcare of Florida and Sunshine State Health Plan.

A second waiver request is pending with HHS.  If granted, it will allow Florida to shift the majority of remaining fee-for-service Medicaid recipients into the Managed Medical Assistance program via an HMO or PSN in the recipient’s area.  On December 28, 2012, AHCA issued the invitations to negotiate seeking managed care organizations to provide Mandatory Managed Medical Assistance to Medicaid recipients in Florida.  It is anticipated that AHCA will post the notice of intent to award these contracts on September 16, 2013.  If the second waiver request has been granted by this time, the anticipated contract execution date is December 31, 2013.

Health Care Reform – Should Employers Reduce Expected Health Costs in 2014 by Transitioning Some Full Time Employees to Part Time Status Now?

February 4, 2013 Leave a comment

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From Akerman’s Health Law Rx Blog:

POSTED BY BETH ALCALDE ON FEBRUARY 1, 2013

2013 is shaping up to be a very busy year for employers in all industries, with the continued implementation of the Patient Protection and Affordable Care Act (“ACA”). Recognizing that in 2014, applicable large employers will avoid ACA-related penalty taxes by offering required affordable group health plan coverage just to full-time employees (i.e., those working an average of 30 hours or more per week, as calculated in a number of permitted ways), some applicable large employers have already begun examining whether to cut their employees’ hours.

Considerations in the reduction of hours decision will vary by industry and by employer, and there is no one-size-fits-all approach. Some of the factors to weigh should include the following:

  • How much will the costs of health coverage continue to rise for this employer? What portion of those costs are expected to be specifically attributable to these employees?
  • What tax savings are currently available for the employer-sponsored coverage for these employees?
  • Are there employee morale, recruitment, productivity, and/or retention issues to consider?
  • Are there public relations or government relations issues to consider?
  • How many part-time employees does the company currently have? Does the company’s business model permit a shift away from full time employment?
  • Will salary increases be needed if no insurance is offered to these employees?
  • How many of these employees are expected to be eligible for subsidized health insurance coverage in a state or federal exchange?  (Note that employers are not advised to solicit pledges from employees to not seek a subsidy in exchange for continued full time employment.)

Akerman’s Health Law Rx Blog

February 4, 2013 Leave a comment

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I am pleased to announce my firm’s new health law blog, Health Law Rx Blog

Akerman’s Health Law Rx Blog provides timely updates on the latest health law issues, keeping the firm’s clients, friends, and readers up to date on pertinent legal developments. Akerman attorneys regularly update the blog with changes in the law and other relevant news. As this is meant to be an interactive site, your comments and contributions are appreciated.  I am one of the contributors, so I hope you will visit the blog often and participate in any discussions that interest you.  I plan to shadow post articles from the blog that I think you will find interesting.

Content on Akerman’s Health Law Rx Blog is intended to inform you about legal developments, including recent decisions of various courts and administrative bodies. It should not be construed as legal advice or a legal opinion, and you should not act upon the information without seeking the advice of legal counsel.

With more than 550 lawyers and government affairs professionals and a network of 19 offices, Akerman is ranked among the top 100 law firms in the U.S. by The National Law Journal NLJ 250 (2012). The firm’s Healthcare Practice Group includes over twenty attorneys and professionals representing health systems, physicians, health insurers, and other clients in all aspects of healthcare law across Florida and throughout the United States.

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