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ACP advocacy and policy development, with other allied organizations, worked to improve your practice environment and help you provide high quality care. Here's a summary of our most important efforts and initiatives in 2014, and why they matter:
1. Progress made to reduce egregious practices by health plans The federal government, the National Association of Insurance Commissioners (NAIC), and health insurer trade groups have acknowledged and begun to take steps to address such egregious practices as narrow provider networks, discriminatory prescription drug benefit packages, and problems with the health plan exception and appeals process.
On multiple occasions, ACP has expressed its concern about discriminatory health insurance benefit packages and tight provider networks that may prevent patients from receiving the care they need from physicians they trust. In February, ACP sent letters to the U.S. Department of Health and Human Services, the NAIC, and health insurance trade groups urging the implementation of patient protections that would ensure that provider networks are accessible, benefit packages are fair and affordable, and patients are able to challenge health plan decisions when necessary care is inaccessible.
In the letter to then-Secretary Kathleen Sebelius, ACP urged that marketplace-based health plans:
Since then, the federal government has issued regulations for qualified health plans offered in federally-operated health insurance marketplaces to closely scrutinize provider networks to ensure patients can access primary care physicians and other health care professionals. Anti-discrimination protections have received enhanced attention, and the agency is considering improvements to ensure prescription drug formulary decisions are made with safety and efficacy — not just cost — in mind. Improvements to the prescription drug coverage appeals process have also been proposed. The NAIC is in the process of updating its network adequacy model act to address narrow and tiered network plans and health insurers have acknowledged that provider network development criteria should be transparent and provider directories should be regularly updated to ensure accuracy.
ACP will continue to monitor these and other important issues that impact the patient-physician relationship.
2. Payment for chronic care management For the first time ever, Medicare will be paying you and your staff for the non-face-to-face work involved with chronic care management (CCM) — beginning January 1, 2015, CMS will make a separate payment via CPT code 99490 for non-face-to-face CCM services for Medicare beneficiaries who have multiple (two or more) chronic conditions. This is an historic, albeit incomplete, step to getting the agency to recognize the value and complexity of the work of ACP members and their staff in managing patients with chronic illnesses that fall outside of the traditional face-to-face office visit. While the payment level is too low, and administrative requirements too burdensome, ACP believes that CMS' decision to begin paying for the new code can lead to further changes in getting Medicare to more appropriately pay for the work that falls outside of the traditional face-to-face office visit.
CMS has established a payment rate of $42.60 for CCM that can be billed up to once per month per qualified patient. Rather than create a new G code as proposed previously, CMS is using the new CPT code 99490, with the following description: Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
The College is appreciative of a number of changes CMS made with regards to this code — in response to our comments and those of other aligned stakeholders — including:
However, the College still has several concerns about the CCM code and will continue to advocate for improvements with CMS. Specifically, these concerns are:
More detail on this code, the improvements ACP is seeking, and how to use it can be found in:
+ More details
Global Surgical Codes: The primary issue with global surgical codes is that they were established several decades ago and, despite changes in surgical practices, the basic structures of the global surgery packages are the same as the packages that existed prior to the creation of the resource-based relative value system in 1992. Different from other typical models of bundled payments, the payment rates for the global surgery packages are not updated regularly based on any reporting of the actual costs of patient care. There also are no separate PFS values established for the procedures or the follow-up care that are included within the package; therefore, payment for the PFS global packages relies on valuing the combined services together. This means that the surgeon providing the surgery is currently paid for all evaluation and management (E/M) visits that are included in the global service whether all of the included visits are actually provided or not. Additionally, E/M visits that are part of the global surgical package do not require the same level of documentation as E/M visits conducted independently. When an E/M services is performed outside a global service, the clinician is required to document the key components of a visit; however, this is not the case when a visit is conducted as part of the global service package. This change to global surgical codes will now require all visits be documented equally. This change will also allow internists (not only surgeons), when appropriate, to perform and be reimbursed for visits that are included in the global service. ACP has been advocating for these 90- and 10-day global surgical codes to be transitioned to 0-day global codes for several years and is pleased that CMS has made the decision to move forward in this manner. The College plans to work with CMS and other stakeholders to map out a process for implementation of this transition.
Proposed Code Values: CMS finalized that beginning with the PFS proposed rule for CY 2016, CMS will include the proposed values for all new, revised and potentially misvalued codes for which CMS has complete RUC recommendations by February 10 th of the preceding year (this is a change from the proposed deadline of January 10 — a change that the College had called for in our comments). For RUC recommendations received after February 10, CMS will delay revaluing the code for one year and include proposed values in the following year's rule. However, there will be flexibility in the implementation of the process for CY 2016 in that for any new, revised, and misvalued code recommendations received after February 10, 2015, CMS plans to establish interim final values for them for CY 2016, consistent with the current process. This phased implementation is intended to ensure that those who have requested new codes and modifications in existing codes with the expectation that they would be valued under the PFS for CY 2016 will not be negatively affected by the timing of this change.
Then, beginning in CY 2017, for a revised or misvalued CPT code value recommendation received after February 10 th, CMS will create a G code for the next year to describe the predecessor code — since it will no longer be listed in the CPT manual-and pay at the old rate until it is revalued.
4. More flexible Meaningful Use criteria While more improvements are needed, the Centers for Medicare & Medicaid Services (CMS), allowed physicians and other health care providers greater flexibility in how they use certified electronic health record (EHR) technology (CEHRT) to meet Meaningful Use for the 2014 reporting period. CMS also extended Stage 2 Meaningful Use through 2016.
In a final rule released in August 2014, based on comments received by ACP and a number of other organizations, CMS recognized the problems that many clinicians were facing in terms of being able to meet the EHR Incentive Program requirements. Therefore, CMS finalized that for eligible professionals (EPs) unable to fully implement 2014 CEHRT due to delays in certification by their vendor, they could attest using 2011 CEHRT or a combination of 2011 and 2014 CEHRT. The rule also finalized the extension of Stage 2 through 2016 for certain clinicians and announced the Stage 3 timeline, which will begin in 2017 for those who first became meaningful EHR users in 2011 or 2012. More information on this rule can be found here.
On January 29th, 2015, CMS announced its intent to engage in rulemaking for EHR Incentive Program changes for 2015. CMS is considering shortening the 2015 reporting period to 90 days and modifying other aspects of the program to match long-term goals, reduce complexity, and lessen clinicians' reporting burden. This comes on the heels of input from ACP, and other stakeholders, which specifically asked for these changes among others.
ACP is continuing to push for further, broader improvements in the meaningful use program, including specific clinical quality measure concerns, how meaningful use measures are scored (i.e., the all or nothing/pass-fail requirement), and issues related to the program being overly prescriptive and burdensome. The College will also be closely monitoring the expected rulemaking process for stage 3 of meaningful use and plans to provide robust comments to both CMS and ONC at the appropriate time. More information on our most recent specific asks can be found here and here.
In the final Physician Fee Schedule rule for 2015 (released in November 2014), CMS modified the quality scoring system to recognize and reward ACOs that make year-to-year improvements in quality performance scores on individual measures. This is in addition to the current strategy the Agency has employed of rewarding quality points based upon meeting absolute performance thresholds. CMS also finalized an increase in the number of potential quality points (from 2-4 points) obtainable from year-to year improvement.
In a proposed rule for the Medicare Shared Savings (ACO) Program released by CMS on December 1, 2014, CMS proposed that ACOs under the model that share savings but not financial losses will get more time to transition to a two-sided risk model. This change would let ACOs experience one-sided risk for an additional three years. Current rules require that ACOs under one-sided risk can only continue in the program if they begin to share financial losses after their initial agreement period. At this time, more than 98% of ACOs in the Shared Saving Program are operating under the one-sided risk option, and many of these entities have stated that they will not be prepared to accept loss risk at the end of the initial agreement period -- it takes time to develop the necessary infrastructure and learn to effectively manage patients under this new payment model -- This change will provide time for this necessary learning to take place without increasing acceptance of risk. An ACO's initial agreement period is three years. ACP will be providing detailed comments to CMS on this proposed rule outlining our areas of support, concern, and recommendations for improvement.
6. ACP member was appointed Surgeon General Dr. Vivek Murthy, MD, MBA, and ACP member, was confirmed by the Senate in December to be the new Surgeon General of the United States.
Dr. Murthy is an esteemed faculty member at Harvard Medical School and hospitalist at Brigham and Women's Hospital in Boston, Massachusetts. He is a strong advocate for the provision of health insurance coverage to all Americans and is a proven leader who can build coalitions among diverse individuals to ensure better health for our communities.
7. Uninsured rate reached historical low In 2014, the nation moved closer to fulfilling one of ACP's long-standing policy goals - affordable, comprehensive health coverage for all. The uninsured rate is at historic lows, with more than 10 million previously uninsured gaining coverage. 2014 paid enrollment in premium-subsidized qualified health plans offered through the ACA's state marketplace exchanges exceeded projections. The expanded Medicaid program is covering millions of individuals who were previously ineligible for the program.
In 2014, the bulk of the ACA's insurance reforms went into effect, including health insurance premium tax credits that ensure coverage is affordable and new regulations like prohibitions on pre-existing condition exemptions. During the first open enrollment period, nearly 7 million individuals enrolled in marketplace-based health coverage and paid premiums and a November 2014 Gallup survey found that 71% of enrollees were happy with their coverage. A recent Gallup poll found that the rate of uninsured U.S. adults had dropped from 17.1% at the end of 2013 to 12.9% at the end of 2014, the lowest since Gallup began asking people about their insured status. A study in the New England Journal of Medicine found that in 2014, more than 10 million previously uninsured persons gained coverage. Further, according to the federal government, 76 million people are newly eligible for preventive services without cost sharing such as vaccinations, wellness visits, and cancer screenings. 2015 enrollment in qualified health plans offered through the ACA's exchanges is currently at a pace that will exceed the administration's projections of more than 9 million enrollees. To help inform members about the ACA so they can better serve their patients, ACP launched an updated ACA Enrollment Campaign. The College has developed state-specific resource to educate physicians about the law's coverage reforms, one-pagers with enrollment assistance information for patients, and extensive FAQs and other resources.
As part of an on-going comprehensive advocacy campaign to ensure access to coverage, ACP assisted chapters in their efforts to urge state governments to expand Medicaid eligibility. In 2014, New Hampshire and Pennsylvania elected to expand their Medicaid programs to all eligible individuals with incomes up to 138% of the federal poverty level and Alaska, Indiana, Tennessee, Utah, Montana, and Wyoming are considering expansion. As of December 2014, 27 states and the District of Columbia have decided to expand. With more and more states choosing to expand their programs, Medicaid enrollment swelled by 15% from February to August 2014. The College will continue in its efforts to help chapters educate their state leaders about the importance of Medicaid expansion.
8. Increased funding to train primary care physicians A key federal primary care workforce program, the Title VII Health Professions program, received a significant increase in funding for FY 2015. This is the only federal program dedicated to funding and improving training of primary care physicians.
Title VII will receive $254.98 million in FY2015, $9.64 million more than in FY2014. Within Title VII, training in Primary Care Medicine will receive $38.92 million, $2 million more than in FY2014. This funding was secured as part of the final federal appropriations bill for FY 2015.
Title VII is the nation's only federal program with the specific objective to produce a diverse, well-trained, primary care workforce. The General Pediatrics, General Internal Medicine, and Family Medicine programs provide critical funding for primary care training in community-based settings and have been successful in directing more primary care physicians to work in underserved areas. They support a range of initiatives, including medical student training, residency training, faculty development and the development of academic administrative units. In a difficult fiscal climate, ACP is pleased by the increases in funding for Title VII and Training in Primary Care Medicine as they were key priorities during Leadership Day 2014. More information can be found in ACP's summary of the 2015 CRomnibus Appropriations Bill.
9. Reduced administrative burden on physicians While more improvements are needed, CMS and Congress took steps to reduce the administrative burden on physicians:
Home Health Care Services change: The documentation requirement by CMS of a face-to-face visit for payment of home health care services has been viewed by a number of physician organizations, including the College, as unnecessarily burdensome. The new appropriations agreement specifically states that "in the fiscal year 2016 budget request, CMS quantify and explain how the policy directing physicians to conduct face-to-face certifications for home health care has prevented fraud, increased access to health care, and impacted costs to the Medicare and Medicaid programs. The agreement requests that CMS include in the budget request how provider documentation for face- to-face encounters can be simplified." (For more information, see page 69 here.)
Medicare Shared Savings Program proposed change: The Medicare Shared Savings Program Rule proposes to simplify and facilitate the process by which participants obtain necessary demographic and clinical data on beneficiaries attributed to them. In addition, the rule specifically recognizes the administrative burden and cost associated with program participants providing clinical patient and other data to CMS and that the Agency is committed to take action to address these factors in data requests in the future. The full proposed rule is available here.
We are continuing to make progress in other areas as well, due to ACP advocacy and policy development efforts, working with other allied organizations.
Bill to repeal the SGR Although Congress failed to complete action to repeal the Medicare Sustainable Growth Rate (SGR) in 2014, for the first time, a bipartisan, bicameral agreement on a bill to repeal the SGR made it through the health care authorizing committees and to the floor of both the House and Senate. This bill included positive incentives for physicians in Patient-Centered Medical Homes and other innovative payment and delivery system models, while improving existing Medicare quality reporting programs. It is expected that this bill will be the basis for legislation in the new 114th Congress.
ACP applauded the agreement reached by key Medicare committees in the House and Senate on comprehensive legislation to finally repeal Medicare's physician payment system, known as the Sustainable Growth Rate (SGR). This legislation, the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015/S. 2000), has bipartisan support in Congress and has the support of over 65 medical organizations, including ACP.
This legislation represents a momentous opportunity for Congress to finally repeal this flawed formula and move to a new system that brings better value to patients and to the entire health care system. Among other things, this legislation:
Legislation to extend the Medicaid Primary Care Parity Program While not enacted into law, legislation was introduced in both the House and Senate (H.R. 5723 and S. 2694) to extend the Medicaid Primary Care Parity Program beyond its 2014 expiration date. This program ensures that Medicaid rates for primary care and immunization services are paid at least the rate of Medicare for years 2015 and 2016.
This legislation, the Ensuring Access to Primary Care for Women & Children Act, was introduced by Sens. Sherrod Brown (D-OH) and Patty Murray (D-WA) in the last Congress and would help ensure access to vital primary care services for our nation's most vulnerable citizens by preventing pending cuts in Medicaid payments for certain primary care and immunization services. With a new Congress having begun in January 2015, this legislation will have to be reintroduced for further consideration.
This legislation would extend and ensure continued federal funding of this program through 2016; it ensures that physicians practicing in the specialties of family medicine, pediatrics, and internal medicine as well as related internal medicine and pediatric subspecialists continue to receive Medicare-level reimbursement rates for providing primary care and immunization services to patients enrolled in Medicaid; it also includes physicians practicing obstetrics and gynecology as qualified specialists, subject to the eligibility requirement that at least 60% of their Medicaid billings consist of primary care services as defined under current law.
With the continued shortage among primary care and other specialists, the reauthorization of this program is critical for the following reasons:
