Lawmakers averted a year-end deadline for Medicare physician payment cuts after the House reversed course Dec. 23 by supporting a two-month patch for the physician payment formula. President Obama then signed the measure blocking the 27.4 percent pay cut, setting up another showdown in the first two months of 2012 when Congress returns to Washington.
MedPac has endorsed a plan to repeal the SGR formula and replace it with one that keeps payment rates steady for primary care physicians over the next decade and cuts payments to specialists. The proposal will reach Congress later this month. If Congress does not act on the MedPAC plan or come up with an alternative before Jan. 1, a 30% across-the-board cut in Medicare payments mandated by the SGR will go into effect
PHRsSGR Repeal Proposal: The Medicare Payment Advisory Commission presented a draft of its propsal to repeal the sustainable growth rate. The plan is currently under discussion by the Commission but will not be voted on until the October 6-7, 2011 meeting.
PHR Model Privacy Notice: Federal officials announced a voluntary Personal Health Record Model Privacy Notice. The notice aims to provide a standardized template to help consumers compare and make decisions about PHR products based on their data practices, as well as privacy and security policies
Patients would have direct access to their laboratory test results under a proposed rule issued by HHS (HHS release, 9/12). The proposed rule in the Sept. 14 Federal Register would modify the Clinical Laboratory Improvement Amendments of 1988 and the Health Insurance Portability and Accountability Act of 1996. These two statutes limit the release of test results directly from laboratories to patients in states that do not have laws allowing test results to be given to patients directly.
Health Insurance Exchange
HIEs: HHS has proposed Health Insurance Exchange Rules to assist states in building mandated competitive health insurance marketplaces.
NYS health exchange bill: The New York Health Benefit Exchange Act (S. 5849) passed the Assembly last month. The Senate has not yet passed the legislation, but is expected to come back to Albany later in the year to pass the bill or a variation of it. Read MSSNY's summary of the bill.
Health Insurance Exchange: Last spring, the NYS Insurance Department held public forums to present their ideas on the design of the state's health insurance exchange. Robert J. Hughes, MD, FACS, president-elect of the Medical Society of the State of New York, presented testimony at a public forum held on May 16, 2011 in Albany. Click here to read his statement.
Accountable Care Organizations
Keep up to date with what’s happening at the Innovation Center—look below for press releases, fact sheets, speeches, and other materials.
A template of the application for the Advance Payment ACO Model is available on the new Advance Payment Model Application Information webpage. The updated information on the webpage explains the application process, including how to obtain log-in credentials for the web tool.
Three new initiatives for providers: The Centers for Medicare & Medicaid Services announced three new initiatives for providers interested in forming accountable care organizations (ACOs). The Pioneer ACO Model is targeted to organizations that have already begun coordinating patients, allowing providers to move more rapidly from a shared savings payment model to a population-based payment model consistent with, but separate from, the Medicare Shared Savings Program. The Advanced Payment ACO would let certain providers get their expected savings up front as an incentive to invest in care coordination. The third initiative, Accelerated Development Learning Sessions would help educate providers on ways to improve delivery and coordination.
Accountable Care Organizations: The Department of Health and Human Services has released for public comment the long-awaited proposed rules governing accountable care organizations. Here are some other resources from the Department of Health and Human Services on the proposed ACO regulation:
ACO Overview Fact Sheet
ACO Fact Sheet Summary of Proposed Regulations
ACO Fact Sheet for Providers
ACO Fact Sheet for Consumers
ACO Fact Sheet on Legal Issues Around ACOs
ACO Fact Sheet On Quality Scoring
Accountable Care Organizations – Panacea or Placebo?
By: Mathew J. Levy, Michael J. Schoppmann & Stacey Lipitz Marder
Since the passage of the Patient Protection and Affordable Care Act of 2010 (PPACA) brought about the introduction of a previously heretofore unheard of concept known as a “accountable care organizations” (ACOs), there has been a growing conversation in the medical community centered around two primary questions ‐ what are ACO’s and what do the foretell as to the future of medicine? ACOs were introduced as a Medicare savings program, intended to enhance quality, improve beneficiary outcomes and increase the value of care through incentives to healthcare providers. Although PPACA mandates that the federal government establish an ACO‐based Medicare shared savings program by January 1, 2012, at this juncture there has been little guidance issued by the federal government with respect to these ACOs and how they will be structured. more
Transcript October 5, 2010: Donald Berwick: The administrator of CMS discusses Accountable Care Organizations, and Implications Regarding Antitrust, Physician Self-Referral, Anti-Kickback, and Civil Monetary Penalty Laws
Medical Home
Patient centered medical home: John M Ventura, DC, a charter member of the MCMS Integrated Health Committee, has written an article about the application of patient centered medical home characteristics to spine care that was published in Becker’s Orthopedic, Spine and Pain Management magazine, published April 12, 2011..
Red Flags Rule
Red Flag Appeals Court Ruling Victory for Physicians: A federal appeals court issued a decision that further validates the American Medical Association's long-standing argument to the Federal Trade Commission (FTC) that physicians who bill after rendering services are not subject to the red flags rule as creditors.
Clarification Act of 2010: President Obama has signed into law the Red Flag Program Clarification Act of 2010.This legislation narrows the scope of the Red Flags Rule's definition of "creditor" and relieves some physicians of having to comply with the FTC’s identity theft prevention law.
The Obama administration released regulations November 22, 2010 detailing a health law requirement that insurers must spend 80 percent to 85 percent of premiums on medical care.
Medical Loss Ratio Rule
NAIC Moves Forward With Medical Loss Ratio Rules
The National Association of Insurance Commissioners (NAIC) approved a proposed financial template, called a "blank," specifying the types of spending that health insurers may be able to count as medical expenses under the new medical loss ratio requirements set by the Patient Protection and Affordable Care Act. The commissioners moved forward with 10 of 11 proposed amendments that further narrowed the types of expenses and fees that insurers would be allowed to count toward MLR calculations. Begining in 2011 insurers operating in the large group market must spend at least 85 percent of premium revenue on medical care for subscribers, rather than on administrative costs or profits. The MLR for individual and small-group health plans must be at least 80 percent. Regulators will review the blank forms and calculate where the insurers stand in relation to those requirements, and if they fall short, the insurer must rebate the excess profits back to their customers.
Medicare/Medicaid
AMA comments on Final Rules of Meaningful Use
A memo to the board of trustees says the requirements are improved but still ask too much of doctors.
CMS Reviews PECOS Enrollment
(June 30, 2010) The Centers for Medicare and Medicaid Services (CMS) is working with providers to address concerns about enrollment in the Provider Enrollment, Chain and Ownership System (PECOS). (more)
Medicare Payment Fix Passed
(June 25, 2010) President Obama signed into law the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.” This law establishes a 2.2 percent update to the Medicare Physician Fee Schedule (MPFS) payment rates retroactive from June 1 through November 30, 2010. The Centers for Medicare & Medicaid Services (CMS) has directed Medicare claims administration contractors to discontinue processing claims at the negative update rates and to temporarily hold all claims for services rendered June 1, 2010, and later, until the new 2.2 percent update rates are tested and loaded into the Medicare contractors’ claims processing systems. Effective testing of the new 2.2 percent update will ensure that claims are correctly paid at the new rates. CMS says it expects to begin processing claims at the new rates no later than July 1, 2010. Claims for services rendered prior to June 1, 2010, will continue to be processed and paid as usual.
Claims containing June 2010 dates of service which have been paid at the negative update rates will be reprocessed as soon as possible. Under current law, Medicare payments to physicians and other providers paid under the MPFS are based upon the lesser of the submitted charge on the claim or the MPFS amount. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed. Affected physicians/providers who submitted claims containing June dates of service with charges less than the 2.2 percent update amount will need to contact their local Medicare contractor to request an adjustment. Submitted charges on claims cannot be altered without a request from the physician/provider. Physicians/providers should not resubmit claims already submitted to their Medicare contractor.
Temporary Medicaid Fix Passes House, Senate
(June 24, 2010) Shortly after 7:00 Eastern time Thursday evening, the House passed H.R. 3962, which provides a 2.2 percent Medicare fee schedule update for physician services through November 2010. The bill passed by a bipartisan vote of 417 to 1. Since the same legislation passed the Senate last week, the bill will be sent promptly to President Obama’s desk to be signed into law.
The 2.2 percent update provided by H.R. 3962 would replace the 21 percent Medicare cut currently in effect, and be applied retroactively to claims for services provided on or after June 1.
On June 18, the Senate passed an amended version of H.R. 3962, now called the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010,” by unanimous consent.
Patient Protection and Affordable Care Act and the subsequent reconciliation bill (more)
SUMMARY from MSSNY: WHAT HCR PASSAGE MEANS FOR NYS PHYSICIANS
The House of Representatives on Sunday night in separate votes approved the Senate health reform bill (HR 3590) which now proceeds to President Obama to be signed into law, and the so-called "corrections" bill (HR 4872) which contains a series of changes favored by the House. Many provisions in the bill will positively benefit physicians as well as their patients. However, there are other issues which MSSNY has serious concerns and will continue to work aggressively with the AMA and the New York Congressional delegation to address. The American College of Physicians, the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Cardiology, the American Osteopathic Association, the National Medical Association and the National Hispanic Medical Association each announced support for the bill. The American Medical Association, while noting that the bills are imperfect, announced its qualified support for the measure. Analysis of these enormous bills is underway. Click here for an interim summary of some of the positive and negative aspects of these bills.
The President's proposal puts American families and small business owners in control of their own healthcare, click here.
The Patient Protection and Affordable Care Act Implementation Time Line
SRG Announcement (April 16, 2010) |
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