At their interim meeting last week, the American Medical Association (AMA) adopted an SFMS resolution regarding the controversial issue “crisis pregnancy center” and the (lack of) service it provided. This issue has been debated locally and the resolution, authored by SFMS delegate Leslie Lopato, MD, and staff member Steve Heilig, MPH, was adopted by the CMA House of Delegates in October.
The AMA policy states:
AMA supports regulations that require any entity offering crisis pregnancy services to disclose information onsite, in its advertising, and before any services are provided concerning the medical services, contraception, termination of pregnancy or referral for services, adoption options or referral for such services; and,
AMA advocates for any entity providing medical or health services to pregnant women who market medical or any clinical services need to abide by licensing requirements and have the appropriate qualified licensed personnel to do so and abide by federal health information privacy laws.
Last week, CMS released its final rule on the Medicare Shared Savings/ACO program which was outlined in our October 20 post “HHS Releases Final Regulations For Accountable Care Organizations.” Also released was a new Advanced Payment initiative specifically for physician organizations, a final FTC-DOJ Policy Statement on Antitrust Enforcement for Medicare ACOs, and an Interim Final Rule on fraud waivers for Medicare ACOs.
Based on AMA’s preliminary review, there are significant changes to the Final Rules and significant advocacy wins for the AMA and physicians. While AMA staff is now reviewing in detail, the following changes have been made to the rule that are very positive and reflect AMA comments on the proposed rules:
ACO Payment and Structure
The standard financial model for ACOs will still be shared savings, i.e., there will be no change in the underlying payment system, and the program will function essentially as a pay-for-performance program based on total cost. However, they are creating a complementary program through the Innovation Center to provide “Advance Payments” specifically to physician organizations and rural providers that do not have the capital reserves available to finance needed changes in care processes or to cover short-term losses while waiting for shared savings payments to be made.
There will still be two different tracks for ACOs, but one will be “upside only” during the three-year contract period, i.e., the ACO will not be liable to pay CMS if costs actually increase. The second will be both upside and downside, as in the proposed rule. (The proposed rule made ACOs even in the first track liable to pay CMS back for cost increases in the third year.)
There will no longer be requirements to withhold shared savings payments to cover potential future cost increases.
ACOs will be allowed to share in savings beginning with the first dollar of savings earned. The proposed rule gave ACOs a share of savings above a minimum threshold. ACOs must still meet a minimum threshold of savings but they can earn back more of the savings they generate.
There will be 33 quality measures instead of 65, and they have dropped the Hospital Acquired Conditions (HAC) measures, as we urged. There will be no flexibility, though, for different quality measures in different regions.
They will have a more prospective method of assigning beneficiaries. ACOs will get a list of “probable beneficiaries” and the list will be updated quarterly. There will still not be mechanisms for beneficiaries to sign up voluntarily, though; the ACO will only get credit for them after the attribution methodology determines that they have had a majority of their primary care visits with the ACO. In addition, as the AMA recommended, CMS will include primary care services provided by specialist physicians in assigning patients to ACOs, and not limit the attribution method exclusively to primary care physicians.
They eliminated the requirement that at least 50 percent of an ACO’s primary care physicians must be “meaningful users” of EHRs by year 2 of the program. Instead they will double weight the quality measure “Percent of PCPs who successfully qualify for an EHR Incentive Program Payment.” ACOs only have to report a percentage and not meet a specified percentage when reporting this quality measure and the term “qualify” covers PCPs who participate in either the Medicare or Medicaid EHR Incentive program.
There will be a rolling application process, so prospective ACOs will have time to prepare without having to meet arbitrary deadlines that are too short.
Antitrust
FTC-DOJ has adopted two important changes that the AMA requested:
They have eliminated the need for mandatory review of ACOs above the 50 percent threshold of the primary service area (PSA) calculation. While the Agencies will still rely on the PSA calculation, eliminating mandatory review will result in significant removal of burden and cost on potential ACOs.
The statement applies to ALL collaborations among otherwise independent providers. The draft statement applied only to new entities formed after March 23, 2010. This would have placed all collaborations that existed prior to March 23, 2010 under a separate antitrust review system.
Fraud Waivers
CMS and the Office of Inspector General adopted the AMA recommendations that the waivers begin sooner so that they will apply during the process of planning a Medicare ACO, and that ACOs will be able to offer certain additional medical benefits to patients, such as care management, without having them viewed as inappropriate inducements. In addition, the agencies issued the new waivers regulation as an interim final rule instead of a final rule, as the AMA had recommended.
In 1849, Elizabeth Blackwell became the first woman to graduate from medical school. In 1960, Internist Roberta Fenlon, MD, was elected as the first female president of the San Francisco Medical Society. Dr. Fenlon went on to become the first female president of the California Medical Association. There have been many pioneering women physicians to thank and many accomplishments to celebrate this month!
Between 1980 and 2009, the number of female physicians increased 430 percent. The number of women in medicine is steadily increasing, and women comprise nearly a third of all U.S. physicians and half of all U.S. medical students. September is dedicated to recognizing the growing number of women physicians in the profession and their communities.
SFMS, CMA, and AMA are aggressively involved in advocacy efforts related to the most vital issues in medicine today, including medical liability reform, Medicare physician payment reform, expanding coverage for the uninsured and increasing access to care, improving the public health, managed care reform, and others. See below for an update on issues that organized medicine has taken on:
Payment bundling initiative is announced
The Center for Medicare & Medicaid Innovation (CMMI) recently announced a “Bundled Payments for Care Improvement Initiative” and issued a request for applications. The AMA is pleased that the initiative allows for a range of models and gives applicants flexibility in how they organize their programs. There are four basic models (acute care inpatient stay bundle, episode-of-care bundle, post-acute care bundle, prospective inpatient stay bundle).
Interested applicants must submit letters of intent by September 22 for Model 1 and by November 4 for Models 2 through 4. Model 1 projects are expected to get underway in January. The Centers for Medicare & Medicaid Services (CMS) will provide data to the applicants for Models 2 through 4 and work with them to get their projects started in the spring. Click here for more information.
The AMA and other stakeholders strongly opposed a burdensome new Medicare paperwork requirement that was scheduled to take effect in 2011. Following significant outreach to CMS concerning the impact this requirement would have, CMS issued a proposed rule that would retract the policy requiring a physician signature on laboratory test requisitions and reinstate the prior policy that does not require the physician’s signature.
Final rule on electronic prescribing penalty adds flexibility
In response to serious concerns expressed by the AMA about the e-prescribing penalty program that is scheduled to start in 2012, CMS released a final rule that adds flexibility to the exemption categories. This flexibility is intended to make it easier for physicians to avoid the penalty. In addition, CMS has extended the date to apply for an exemption to November 1, 2011. Details of the e-prescribing penalty program can be found in the September 1, 2011 SFMS blog post.
2012 Medicare payment schedule comments are submitted
CMA and AMA submitted comments to numerous proposed policies for the 2012 Medicare physician payment schedule. View CMA’s letter to CMS here. Highlights from the AMA letter include:
With regard to the Physician Quality Reporting System, the AMA urged CMS to allow all measures in groups to be reportable as individual measures, to allow measures for registry reporting to also be reported through claims-based reporting, and expressed concern that CMS has not allowed enough time to test the interest in the Group Practice Reporting Option among groups of two to 24 physicians.
The AMA strenuously objected to designating 2013 as the initial performance year for initial application of the value-based payment modifier in 2015.
AMA comments urged CMS to conduct the promised comprehensive review of the Medicare Economic Index (MEI) and for the review to address the office expense categories and weights that in 2012 will be applied to the geographic practice cost index.
The AMA opposes the proposed multiple procedure payment reduction to the professional component of 119 imaging tests, noting that no savings will be realized if these services move into hospital facility settings.
AMA comments on proposed definition of “patient-centered outcomes research”
AMA along with 26 medical specialty societies, submitted a letter to the Patient-Centered Outcomes Research Institute (PCORI) responding to its call for input on its proposed definition of “patient-centered outcomes research.” The letter conveys support for the proposed broad definition of patient-centered outcomes research, which involves a comparison of different modalities, including health delivery models, to manage a specific health problem, condition, or disease, but seeks clarification on whether a component of the proposed definition includes cost analysis.
More co-sponsors needed on private contracting legislation
The list of co-sponsors for the Medicare Patient Empowerment Act (HR 1700/S. 1042) has expanded, adding Rep. Dana Rohrabacher (R) of California and five physician members of Congress. These bills, introduced by Rep. Tom Price, MD (R-Ga.), and Sen. Lisa Murkowski (R-Ark.) are consistent with policy adopted by the AMA House of Delegates, by allowing private contracting between Medicare beneficiaries and their physicians without penalty to either party.
CMS to require Medicare enrollment revalidation by March 2013
CMS announced in August that it will require all providers and suppliers enrolled in Medicare prior to March 25, 2011, to revalidate their enrollment in Medicare. In an email to providers and in a new “MLN Matters” article, CMS states that Medicare Administrative Contractors (MACs) will send revalidation notices directly to individual providers/suppliers. A provider cannot begin the revalidation process before hearing from a MAC. Upon receiving the revalidation request from a MAC, providers will have 60 days from the date of the letter to submit complete enrollment forms. Click here for full details.
According to CMS, failure to submit the enrollment form as requested may result in deactivation of Medicare billing privileges. The AMA has significant concerns with this revalidation effort in light of the problems physicians had with past enrollment and revalidation efforts. The AMA is making this a priority and urging CMS to reconsider this action.
Medicare Part D open enrollment period starts sooner
As required by the Affordable Care Act, beginning this year the Annual Election Period for the Medicare Part D prescription drug benefit will occur from October 15 through December 7. Patients who need to change Part D plans in order to lower their drug costs or access a different formulary must enroll in their new plan by December 7.
New resource helps practices find the silver lining in cloud computing
Could your members be saving time and money by adopting ASP or cloud computing software? The AMA has developed a new educational resource, “Is an application service provider software or cloud computing service right for your practice,” to shed some light on the advantages, challenges and requirements of using online software applications. This resource discusses various operation models, as well as how physicians and practice staff may determine if one of the models fits their needs and capabilities. It also provides a handy checklist of questions to consider.
After researching and selecting a suitable delivery model, practices may consult the complementary toolkit “Selecting a practice management system,” developed by the AMA and the Medical Group Management Association (MGMA). That resource is designed to help a practice identify specific software which offers the best value for its situation. Visit http://www.ama-assn.org/go/pmc to access both resources.
A proposed deficit deal introduced this week by the so-called Gang of Six senators won the praise of representatives of over 750,000 physicians for its inclusion of a 10-year “doc fix” in Medicare payments.
The Senate's "Gang of Six" includes (clockwise left to right): Democrats Kent Conrad, Dick Durbin and Mark Warner; and Republicans Mike Crapo, Tom Coburn and Saxby Chambliss.
The bipartisan agreement that would slash deficits by up to $3.7 trillion over the next decade includes a 10-year, $298 billion suspension of Medicare’s sustainable growth-rate formula.
The agreement, released Tuesday by the senators who have been negotiating for months, called for spending Medicare and Medicaid funds “more efficiently” without disrupting “the basic structure of these critical programs” but offered few specifics about what that means.
Physician groups, including the American Medical Association and the American Academy of Family Physicians, praised the agreement and urged senators to go even further by fully repealing the SGR.
The proposed agreement also drew criticism from some liberal healthcare advocacy groups for eliminating the CLASS Act, which was included in the Patient Protection and Affordable Care Act. The CLASS Act, a long-term-care insurance program, has drawn criticism that it would produce additional deficit spending.
The bipartisan agreement was praised as “balanced” by President Barack Obama in a brief Tuesday news conference on the looming debt ceiling deadline. Obama stopped short of endorsing the plan.
The Senate group’s deficit-reduction proposal also includes reduced tax breaks on higher-cost health plans and a review of total federal healthcare spending starting in 2020 to hold growth to GDP plus 1% per beneficiary.
The Center for Medicare & Medicaid Innovation (CMMI) recently announced a “Bundled Payments for Care Improvement Initiative” and issued a request for applications. The AMA is pleased that the initiative allows for a range of models and gives applicants flexibility in how they organize their programs. There are four basic models (acute care inpatient stay bundle, episode-of-care bundle, post-acute care bundle, prospective inpatient stay bundle).
In response to serious concerns expressed by the AMA about the e-prescribing penalty program that is scheduled to start in 2012, CMS released a final rule that adds flexibility to the exemption categories. This flexibility is intended to make it easier for physicians to avoid the penalty. In addition, CMS has extended the date to apply for an exemption to November 1, 2011. Details of the e-prescribing penalty program can be found in the 
As required by the Affordable Care Act, beginning this year the Annual Election Period for the Medicare Part D prescription drug benefit will occur from October 15 through December 7. Patients who need to change Part D plans in order to lower their drug costs or access a different formulary must enroll in their new plan by December 7.
