Most members want MIPS repealed, but some concerned about its proposed replacement
This article first appeared November 2, 2017 on Medpage Today.
By Joyce Frieden
WASHINGTON — Although most members of the Medicare Payment Advisory Commission (MedPAC) continue to support repealing Medicare's new Merit-Based Incentive Payment System (MIPS) for physician payment, there was disagreement Thursday about what should replace it.
At a morning meeting, MedPAC staff members presented more details about a proposed replacement for MIPS called the Voluntary Value Program (VVP), and addressed concerns that commission members raised about the program at their last meeting.
MIPS combines parts of the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier, and Meaningful Use into one single program based on quality, resource use, and clinical practice improvement. Under MIPS, doctors earn a payment adjustment based on evidence-based and practice-specific quality data that they report to the Centers for Medicare & Medicaid Services (CMS).
Issues with MIPS
But MedPAC members are concerned that MIPS will not achieve its desired goals. The flexibility of the program — the various options for how physicians can report measures and the broad exemptions for certain types of clinicians — has also made it complex. There are also statistical challenges that stem from trying to develop individual-level performance scores, due to the relatively small case sizes for some providers, David Glass, a principal policy analyst for MedPAC, told the commission during its October meeting:
"Everyone will seem to have high performance when in fact many of the measures are topped out or appear to be topped out ... and that will limit Medicare's ability to detect meaningful differences in clinician performance," he said.
And, speaking at the Thursday meeting, Glass said the program will likely cost about $1 billion in the first year, noting that the commission has raised concerns about the program for the past 2 years.
Under the VVP proposal, all clinicians would see a portion of their fee schedule dollars withheld and lumped into a pool. Clinicians could then be measured with a group of other doctors -- based on population-based outcomes, patient experience, and cost -- to be eligible for value-based incentive payments from the pool. Otherwise, they could decide to participate in an advanced alternative payment model (AAPM) program -- an option they have under the current reimbursement system, in which groups of physicians and hospitals can earn a bonus of up to 5%, based on patient outcomes, in exchange for taking on financial risk. If they chose neither of those options, they would lose all the money withheld.
One advantage of this proposal is that it would drive more clinicians to join AAPMs, Glass said, because they would be more familiar with them from the current program, and because under the VVP, they wouldn't be eligible to receive the 5% bonus that AAPMs pay for meeting quality and outcomes goals. Responding to questions raised by the commissioners, he noted that a minimum of 10 clinicians would likely be sufficient to form a VVP; currently, a third of physicians who bill Medicare work in groups that size or larger. If there isn't a group available for a particular clinician to join, CMS could establish special groups for them, Glass added.
Replacement Program Praised — With Reservations
Most commission members were on board with the VVP idea. "I'm in favor of what's written in this recommendation," said Craig Samitt, MD, MBA, executive vice president and chief clinical officer at Anthem, the big health insurer. However, Samitt expressed concern that a 10-person group would be too small to collect enough cases for meaningful quality measurement. "I worry that for metrics like readmission rates, that size would be too limited."
He also suggested encouraging the formation of specialty AAPMs. "We must accelerate and advance that opportunity so that those homes exist for specialists as much as for primary care physicians."
"I'm encouraged with the direction we're going and supportive of the overall approach," said Jack Hoadley, PhD, of Georgetown University's Health Policy Institute here. However, "it seems like the biggest issue there is risk adjustment -- if you have a group of oncologists and you're measuring the total cost of care, if it's not risk-adjusted you're not going to fare well next to the primary care practice on the other side of town. So think about [risk adjustment] or measures that don't overly penalize [providers] who see people who are [very] sick."
Brian DeBusk, PhD, of DeRoyal Industries in Powell, Tenn., said he supported MIPS repeal "but I would hope to see that specialty APMs are developed in parallel; that would take the pressure off [making the] VVP be all things to all people."
Not Everyone on Board
But not everyone was a fan. "I have very serious concerns about the VVP proposal," said David Nerenz, PhD, of the Henry Ford Health System in Detroit. "You're talking about serious social engineering in the structure of medical practice ... without compelling evidence that the structure we're talking about is good. Lots of us believe in it, but that's not the same as evidence."
In addition, "we're using the term 'voluntary,' but I don't think it's voluntary if there is a penalty for non-participation." If voluntary is what is meant, that penalty should be taken away, Nerenz said, adding that he also "doesn't think this program as proposed engages specialists in any meaningful way."
Alice Coombs, MD, of South Shore Hospital in Weymouth, Massachusetts, said she did not favor repealing the MIPS program. "MIPS has a lot of problems ... but some things coming out of it are good," she said. "I'm concerned about specialists [not participating] ... I voiced that [at the last meeting] and the answers are not appeasing for me."
She praised MIPS measures such as one for hospitals' nosocomial infection rates and another for giving patients antibiotics to cut down on infections. "Inside my world, it makes a difference," she said.
Commission chair Francis Crosson, MD, of Palo Alto, California, tried to reassure her. "I don't want you to read this proposal as MedPAC retreating from measuring surgical outcomes and the like," he said. "But we're saying that doing that at the individual doctor level for purposes of Medicare payment is probably not the appropriate direction to go in ... In terms of other entities, like hospitals ... aggressively pursuing those measures and process improvement, we're all for it."
Spatial, temporal analytics may aid infection control in hospitals.
This article first appeared October 23, 2017 on Medpage Today.
By Alexandria Bachert, MPH
Using electronic health record (EHR) data on time and location allowed researchers to identify a source of a Clostridium difficile at the University of California San Francisco Medical Center.
Exposure to C. difficile infection (CDI) in the computed tomography scanner in the emergency department (CT-ED) was associated with a 4% incidence of CDI (OR 2.5 versus unexposed individuals in the same space; 95% CI 1.2-5.2), reported Russ Cucina, MD, senior study author and chief health information officer at UCSF, and colleagues.
Writing online in JAMA Internal Medicine, they noted that the association remained significant even after adjusting for covariates such as antibiotic use and length of hospital stay (OR 2.7; 95% CI 1.3-5.7), as well as in sensitivity analyses in which the incubation period was extended from 24 to 72 hours (OR 2.8; 95% CI 1.2-6.3).
"Most studies looking at C. diff in hospitals typically only look at whether patients were on the same hospital floor," stated Cucina. "If we just look at transmission in their room, we're missing potential opportunities for disease transmission."
Our novel analytic methods identify a previously undiscovered opportunity for real-world practice change, explained Cucina and colleagues.
Robert Wachter, MD, chair of the UCSF Department of Medicine, who was not involved in the study, agreed: "The electronic health record is a treasure trove of clinical data and insights, but we are just beginning to discover how to unlock its secrets. This study demonstrates the potential to transform patient care when innovative clinicians and technology experts join hands to tackle healthcare's hardest problems," he stated in a press release.
Cucina and colleagues examined EHR data on time and location to map 434,745 patient location changes throughout the UCSF Medical Center at Parnassus from January 2013 to December 2015.
Patients with a CDI were considered C. difficile positive from the time the positive test was ordered until hospital discharge and places were considered potentially contaminated for 24 hours after a patient with CDI visited them.
The researchers noted that hospitalized patients who hadn't yet tested positive for CDI but passed through a potentially contaminated space were considered exposed to C. difficile, while those who were in the same space at any other time were seen as the unexposed group.
Cucina and colleagues found a total of 1,152 cases of laboratory-documented CDI, with CDI-positive patients moving through an average of four locations while hospitalized.
Aside from CT-ED, there were no other significant sources of exposure-related infections and the effect was not significant in an adjusted hospital-wide analysis.
The researchers also reported that a subsequent investigation showed that cleaning practices for the CT-ED didn't match the standardized methods in other radiology suites, spurring the hospital to update the cleaning practices.
Cucina concluded that leveraging EHR data for spatial and temporal analytics may be a widely applicable strategy for infection control and quality improvement.
The researchers reported no financial disclosures of interest.
This article first appeared October 16, 2017 on Medpage Today.
By Joyce Frieden
The American College of Physicians is asking doctors to commit to asking patients about guns and to be willing to add their names to list of colleagues who support this safety conversation initiative.
But do physicians who publicly commit to having this conversation -- or take public stands on other issues -- have to worry about retaliation from opponents, either online or otherwise?
To answer that question, MedPage Today turned to Ron Harman King, who produces the Wired Practice videos featured on MedPage Today.
"Overall, unless you're a celebrity, I'd say the chances of more than a handful of online attacks on most campaign participants are relatively small, and a participant may even find himself or herself gathering new supporters and advocates both online and off-line," said King, owner and CEO of Vanguard Communications, a healthcare marketing firm in Denver, in an email.
"The odds of protesters appearing outside a clinic are small to non-existent, particularly in urban areas," said King. "A clinic might possibly suffer an incidence of graffiti, but I'd be surprised by even that occurrence. If that happens, notify local law enforcement and have the graffiti removed as soon as possible."
He offered physicians these tips for staying safe -- online and elsewhere -- while discussing controversial issues:
If you have a personal Facebook account, adjust your settings so that only people you've accepted as Facebook friends can see posts. If an "internet troll" posts an attack, he and all his friends will see the post, but no one else can. This will limit the exposure of any aggressive comments.
Resist debating anyone on social media, especially if your practice has what's called a Facebook Page, with a capital P, which is reserved for businesses and doesn't have the control that personal Facebook pages offer. Instead, consider drafting -- and having on hand, ready to post -- a boilerplate statement explaining your position on this topic, for example, as a matter of public health and professional ethical obligations, not as a position against gun ownership rights and constitutional freedoms. This could be used as a calm, reasoned response if needed.
At the merest hint of any physical threat to a physician, staff, or patients, contact police immediately. "Having once been a police reporter for a big city newspaper, I can vouch for the effectiveness of some law enforcement agencies and detectives at identifying and safeguarding against troublemakers to be taken seriously," King said. "They often already know who they are."
And finally, "Grow as thick skin as a possible," he advised. "Throughout the ages, scientists from Galileo to Jonas Salk have taken heat for speaking their scientifically based beliefs. Sometimes it comes with the territory of standing up for what one believes is in humanity's best interests."
Argue hospital buyouts of small clinics signal a profit motive.
This article first appeared October 12, 2017 on Medpage Today.
By Shannon Firth
WASHINGTON -- A program that helps lower the costs of prescription drugs for safety net hospitals and clinics has come under scrutiny from the House Energy and Commerce's Oversight and Investigations Subcommittee.
At a Wednesday hearing, subcommittee chairman Rep. Morgan Griffith (R-Va.) lauded some of the so-called 340B program's achievements while also highlighting some concerns.
"I see news accounts indicating that some covered entities spend million on salaries and bonuses for their CEOs and hundreds of millions on building expansions, even as charity care to those entities is on the decline," he said.
The 340B drug pricing program requires drug companies to sell outpatient drugs at a marked discount to safety net providers such as hospitals that treat high numbers of low-income patients -- so-called Disproportionate Share Hospitals (DSH) -- and some publicly funded HIV clinics. A government review indicated that participating facilities saved some $6 billion in 2016 through the program.
Democrats say the program is fulfilling its mission to "stretch scarce Federal resources as far as possible, reaching more eligible patients and providing more comprehensive services."
Republicans, on the other hand, want greater transparency and accountability for the program, and are concerned that some hospitals are milking the system through buyouts of private clinics that sell the costliest drugs.
At a hearing in July, the subcommittee was told the agency lacked the authority to track how or whether hospitals and clinics participating in the 340B program were using savings to enhance care to patients.
On learning of this problem, the subcommittee sent letters to a number of participants requesting the following information:
How much they saved through discounted drug purchases
What level and kind of charity care an entity offered
How patients benefit from participation in the 340B program
At Wednesday's hearing, Rep. Buddy Carter (R-Ga.) asked Shannon Banna, director of finance and system controller for Northside Hospital in Atlanta, whether her hospital system had acquired any oncology clinics since it joined ht program.
Banna said the hospital system was being "encouraged" to expand clinically integrated outpatient care.
Pressed further by Carter, she said that Northside had acquired oncology clinics in 2011 and 2012.
"Are you acquiring the oncology clinics because you have a chance to make more money through the 340B program?" Carter asked point-blank.
"No ... we are being encouraged to expand our clinically integrated model ... " said Banna, who seemed taken aback, before Carter cut her off.
He asked her to "submit in writing" the number of clinics Northside had bought since 1992.
Rep. Chris Collins (R-N.Y.) asserted that hospitals were acquiring oncology clinics solely to reap profits under 340B.
Participating hospitals and health systems in the 340B program saved 25%-50% off the average wholesale price for reimbursable outpatient drugs according to a House E &C Subcommittee press release.
Once bought, these same small clinics would see the cost of cancer drugs -- some of the most expensive in the country -- dramatically reduced, in spite of the fact that most of their patients are fully insured, particularly in the suburbs.
The reason for this is that the definition of what determines a DSH hospital relies only on having a certain percentage of Medicare and Medicaid inpatients and does not factor in the level of outpatient care.
More specifically eligibility is based on the share of inpatient stays by these Medicare and Medicaid patients only, whereas most clinics in the suburbs provide only outpatient care.
This "loophole" means DSH hospitals can acquire oncology clinics without altering their DSH status and continued access to the 340B program.
Several Republicans, including Carter, Collins, and Rep. Greg Walden (R-Ore.), who chairs the full House Energy and Commerce Committee, stressed that the program wasn't on the chopping block and that they were only trying to improve accountability.
Nevertheless, Democrats pressed witnesses to say what would happen if Congress eliminated the 340B program -- their cue to brag about the many services they can provide as a result of participation.
Banna, for example, cited her hospital's management of high-risk maternity patients, community outreach, oncology nurse navigators, and the fact that the hospitals passed on savings directly to patients.
Another witness from Johns Hopkins Hospital in Baltimore, spoke of investments in prevention such as educational programs for expectant mothers and installing railings in elderly patients' homes to prevent falls.
On the issue of hospital consolidation Rep. Raul Ruiz, MD (D-Calif.), said, "The fact that clinics and hospitals are expanding to more communities is a good thing. The fact that you're bringing in ... oncology clinics, for example, that otherwise would be inaccessible through other healthcare systems into your mission driven hospital is a good thing ... The poor and struggling working families also getting cancer. They also need the medications. They also need care."
Rep. Diana DeGette (D-Colo.), ranking member for the subcommittee, compared the savings that each 340B entities achieved through the the program against the total uncompensated or charity care for the entity.
Northside Hospital, for example, produced $53 million in 340B savings, compared to the $370 million in charity care, it reported in 2016, DeGette said.
In more than a half-dozen other examples, 340B savings were only a fraction of the amount of charity care dispensed.
"From what this committee has seen [hospitals] don't seem to be lining their pockets. They're using the savings to provide critical care for the community and vulnerable populations," she said.
DeGette said that she was open to discussing what is and isn't "charity care" and making improvements in transparency.
"In doing so, we should not reduce the providers' ability to fulfill their missions and continue their important work."
MedPAC has been set on defeating the Merit-based Incentive Payment System for a long time; but whether the program should be simply "repealed" or "repealed and replaced" wasn't clear at Thursday's meeting.
This article first appeared October 01, 2017 on Medpage Today.
By Shannon Firth
WASHINGTON -- Health policy experts sometimes battle for consensus over payment issues, but when it comes to the new way of paying most doctors under Medicare, one group reached near-unanimous agreement: Scrap it.
The Merit-based Incentive Payment System (MIPS) should be spiked, virtually all members of the Medicare Payment Advisory Commission (MedPAC) said during a meeting on Thursday morning.
MedPAC, whose members include physicians, healthcare executives, and other policy experts charged with advising the Department of Health and Human Services on Medicare policy issues, has been set on defeating MIPS for a long time; but whether the program should be simply "repealed" or "repealed and replaced" wasn't clear at Thursday's meeting.
At the start of the meeting, MedPAC's analysts addressed the challenges with the MIPS program and proposed a potential alternative.
The main problem with the MIPS program, as MedPAC's analysts see it, is that MIPS won't achieve the policy goals that it's designed to achieve.
The flexibility of the program -- the various options for how physicians can report measures and the broad exemptions for certain types of clinicians -- has made it overly complex. There are also statistical challenges that stem from trying to develop individual-level performance scores, due to the relatively small case sizes for some providers.
"Everyone will seem to have high performance when in fact many of the measures are topped out or appear to be topped out ... and that will limit Medicare's ability to detect meaningful differences in clinician performance," said David Glass, a principal policy analyst for MedPAC.
In the end, Medicare gives clinicians a score based on their performance and either raises or reduces their Medicare payment based on that score, but for all the reasons Glass mentioned, he believes it is "extremely unlikely that physicians will understand their score or what they need to do to improve it."
"Our most basic concern is that the measures in MIPS have not been proven to be associated with high-value care," he said.
Alternative Proposed
Glass and MedPAC senior analyst Kate Bloniarz suggested an alternative policy approach that leverages population-based measures.
The Voluntary Value Program, as they've dubbed the alternative, would get rid of the MIPS program and all three types of reporting requirements -- Advancing Care Information (ACI), Clinical Practice Improvement Activities (CPIA), and quality measures -- and scrap CMS support for Electronic Health Records reporting.
In the new model, all clinicians would see a portion of their fee schedule dollars withheld, which would be lumped into a pool -- for example 2%, though analysts stressed the percent amount had not been decided.
Clinicians would then have three options:
Choose to be measured with a "sufficiently large entity" of clinicians and be eligible for value payments
Choose to participate in an advanced APM model
Lose the withheld fee schedule dollars
In the first option, the "sufficiently large entity" could be those physicians affiliated with a single hospital or one geographic area, she said.
"An entity's performance would then be collectively measured using a set of population-based measures," Bloniarz added.
A limitation of the model is that entities must be "sufficiently large" in order to have "statistically detectable performance on the population based measures."
In the Voluntary Value Program, measures could potentially fall under three categories: clinical quality, patient experience, and value. For example, a clinical quality measure might include mortality or avoidable admissions.
Unlike the MIPS program, all of the measures could be pulled from Medicare claims data or "centrally conducted surveys" avoiding the clinician reporting burden, Bloniarz explained.
Repeal and Replace?
Most members of the commission expressed support for the new model or at least felt it was a good start.
One new commissioner, David Grabowski, PhD, of Harvard Medical School in Boston, said he favored having a replacement, but he worried that some physicians, particularly those in rural areas, or those treating dual eligible patients (enrollees in both Medicare and Medicaid) might be left out. He stressed that incorporating proper risk adjustment mechanisms into the measurement process would be critical.
Paul Ginsburg, PhD, of the Brookings Institution, also supported a repeal-and-replace strategy.
"My sense is that the politicians don't want to do nothing. They want to do something," he said.
However, several commissioners were more hesitant, asking whether replacing the MIPS program was necessary.
"Are we creating something that is so close to the advanced APM structure that it's almost not worth it?" asked Dana Gelb Safran, ScD, of Blue Cross Blue Shield of Massachusetts.
Gelb Safran suggested that if the commission does choose to recommend an alternative, distinctions between it and the APMs would need to be clear. She also wondered aloud whether with these new entities would revive some of the challenges of the old SGR formula.
The challenge with the SGR was that individuals weren't truly accountable to each other even though they were lumped together, she explained.
"That really undercuts the desire to behave in the way that the incentives should make them behave because somebody else could kill their incentive, so why bother."
Craig Samitt, MD, MBA of Anthem in Indianapolis, said he would favor a repeal-only approach, based on the replacement model he'd seen that day.
"If a replacement is a voluntary model that would allow us to keep practicing healthcare the way we've been practicing, then that replacement is not a good replacement," Samitt said.
MedPAC member Kathy Buto, MPA, of Arlington, Virginia, suggested another idea: repeal the MIPS program, but continue to withhold the funds from the clinicians who aren't participating in the advanced APMs. Then use those dollars to reward APM performance.
"I would actually increase the penalty and make it less attractive to stay in MIPS regardless," she said.
Commission Chairman Francis J. Crosson, MD, joked that he would be happy to escort Buto from the meeting after it adjourned -- implying her idea might be dangerously unpopular with physicians.
In the end, Crosson determined that MedPAC's technical team would return to the group with draft recommendations for repealing the MIPS program and offer two options: a voluntary replacement program similar to the one discussed at Thursday's meeting with some revisions, and suggestions on how to make the advanced Alternative Payment Models more accessible for physicians.
The commission could then decide whether to recommend one or both options to HHS.
Healthcare policy experts from the Urban Institute and CareFirst BlueCross BlueShield debate its advantages and disadvantages.
This article first appeared September 27, 2017 on Medpage Today.
By Shannon Firth
WASHINGTON -- Does the Medicare Physician Fee Schedule have a role in the move towards value-based payment, and if so, how much time and resources should be devoted to fixing it? Policy scholars tackled this question at a USC-Brookings Schaeffer Initiative for Health Policy briefing on Tuesday.
"I think we need to be paying a lot of attention to the fee schedule, while we are also trying to support alternative payment models," said Robert Berenson, MD, an Institute fellow at the Urban Institute, which co-hosted the briefing. Berenson oversaw Medicare payment policy and private health plan contracting for the Centers for Medicare and Medicaid Services (CMS) from 1998 to 2000.
He now serves as a member of the Physician-focused Payment Technical Advisory Committee (P-TAC), which is tasked with evaluating proposals for new alternative payment models (APMs) and making recommendations to the secretary of the U.S. Department of Health and Humans Services (HHS). Berenson cautioned that he spoke for himself and not for PTAC at the briefing.
Borrowing a phrase from the play "The Doctor's Dilemma," by George Bernard Shaw, Berenson asked why "we should give a surgeon money for taking off your leg, and nothing for keeping it on?"
"Your rewarded for doing stuff, some of which is unnecessary, and not rewarded for not doing stuff," he said of the fee schedule.
While coding may have drawbacks, "not everything needs to be solved with a payment model," Berenson added. In his view, hybrid payment models that balance "the incentives for stinting with the incentives for overproducing" are the ideal goal.
As an example, Berenson cited the second track of the Comprehensive Primary Care (CPC) Plus model, which relies on the fee schedule, but also includes a per-member, per month care management fee.
Potential Fixes
One way the fee schedule could be modified is to reduce disparities in payments across specialties, Berenson noted. Rather than requiring Congress to legislate changes to the fee schedule, as is the current situation, the HHS Secretary should be given the authority to move money around.
For example, the Resource-based relative value scale (RBRVS) -- the system used to calculate payment rates for physicians -- could govern 95% of spending. But the remaining 5% could be within the the discretion of the secretary to achieve certain policy objectives, he told MedPage Today.
"We have no geriatricians for an aging population. Virtually none who are actually practicing ... And I think a fee schedule could be constructed to reward more generously the services that certain specialties perform," he said.
He underscored other implications of fixing the fee schedule for the APMs.
When some specialties earn two or three times what primary care doctors make in a fee-for-service system, there's less incentive for the specialists to join multispecialty practice groups, he said.
But it's these types of groups that are well-positioned to develop episode based-payment bundles, capitated payment, or other value-based models, he noted. As a result, fixing the fee schedule is critical to advancing APMs, Berenson suggested.
APM Challenges
Jonathan Blum, executive vice president of medical affairs at CareFirst BlueCross BlueShield (BCBS) and a former principal deputy administrator for CMS, agreed that improving the fee schedule is vital.
With the data he has access to in his current role, Blum said he's more skeptical than before about the future of APMs.
Data shows that Care First BCBS members travel to different hospital systems for different health needs, he explained. Neither the private payer world or the Medicare program are "comfortable" dictating where people receive care, Blum noted.
Yet, when the policy community talks about clinical bundles and capitated payments that lock people into a given delivery system, they ignore this fact, he stated
He also pointed out that the policy community may see a wide spectrum of costs and outcomes in a geographical area and think that they can be shifted. For example, the reasons why a patient may choose a skilled nursing facility over home healthcare care might have more to do with practical matters -- there's no one available to let the home heatlhcare worker in and out of the house -- than clinical ones. Patients don't always follow "rational care patterns," he said.
While capitated APMs are a "worthy goal," Blum said, "we have to find the resources, the staff, the money, the contract dollars to make sure that we're paying accurately, because I will predict ... the fee-for-service system, will still be in place 20 years from now, 30 years from now, unless we start being comfortable locking people into one system of care."
Focus on Outcomes
Gail Wilensky, PhD, an economist and senior fellow at Project Hope, said while she agrees that having a more accurate fee schedule is beneficial, she worries about "the bandwidth" and political capital at CMS, the Medicare Payment Advisory Commission (MedPAC), and P-TAC.
"For me, even an improved fee schedule [that] maintains its very micro-level focus is not going to help us move forward in terms of trying to improve quality and outcomes," she said.
Rather than improving the fee schedule, Wilensky said the focus of payment reform should be to streamline the number of outcomes measures to those that actually matter, so that they can be expanded to more payers.
The fee schedule was specifically designed so that payment would be the same regardless of who performs the services, she pointed out. Now that people are unhappy with the resulting income distributions, some want to see it changed.
But when quality and outcomes aren't important, and input costs are, "it's hard to imagine a more challenging way to go change income distributions then to have a micro-unit focused fee schedule," she said.
With one exception, most physician groups stating a position viewed the bill as dangerous.
This article first appeared September 21, 2017 on Medpage Today.
By Shannon Firth
WASHINGTON -- As momentum builds for the GOP's latest Obamacare repeal effort, most major physician and hospital groups skewered the proposal.
But some held their tongues or even welcomed certain new "freedoms" the bill could afford.
Last week senators Lindsey Graham (R-S.C.), Bill Cassidy (R-La.), Dean Heller (R-Nev.), and Ron Johnson (R-Wis.) introduced a healthcare bill to pool money that would have been funnelled into premium and cost-sharing subsidies and Medicaid expansion and direct it instead to states in the form of block grants.
The proposal would also repeal the Affordable Care Act's individual and employer mandates, the medical device tax, and "strengthen the ability for states to waive Obamacare regulations," according to a Sept. 13 press release posted on Cassidy's website. It appears the bill will have no committee hearings or markups before coming to the Senate floor for a vote.
With one exception, most physician groups stating a position viewed the bill as dangerous.
Physicians: 'Do No Harm'
The new bill "violates the precept of 'first do no harm,'" said James Madara, MD, CEO and executive vice president of the American Medical Association, in a letter to Senate Majority Leader Mitch McConnell (R-Ky,) and Minority Leader Chuck Schumer (D-N.Y.).
"Similar to proposals that were considered in the Senate in July, we believe the Graham-Cassidy Amendment would result in millions of Americans losing their health insurance coverage, destabilize health insurance markets, and decrease access to affordable coverage and care," he wrote.
The AMA is especially concerned about repealing the premium subsidies, cost-sharing reductions, small business tax credits, and Medicaid expansion, and described the Medicaid block grants, which would run through 2026 as "inadequate and temporary."
"Per-capita caps (a form of block grant) fail to take into account unanticipated costs of new medical innovations or the fiscal impact of public health epidemics, such as the crisis of opioid abuse currently ravaging our nation," he wrote.
Rebecca Parker, MD, president of the American College of Emergency Physicians, also penned a letter to Senate leadership highlighting the dangers her members see in the bill.
"ACEP cannot support any legislation that does not include emergency medical care as a covered benefit in health insurance," she wrote. "Yet, [the Cassidy-Graham bill] allows states to easily forego requiring insurers to adhere to important consumer protections, including the requirement to cover the ten essential health benefits, and protections for those with pre-existing conditions."
Ninety-five percent of Americans believe health plans should cover emergency medical care, Parker noted, which is currently one of the ACA's essential benefits.
"[E]mergency physicians agree with them. Patients can't choose when and where they will need emergency care, and they shouldn't be punished financially for having emergencies," she continued.
And a joint letter from six specialty organizations representing more than 500,000 physicians -- the American Academy of Family Physicians, the American Academy of Pediatrics, the American Congress of Obstetricians and Gynecologists, the American Osteopathic Association, the American College of Physicians, and the American Psychiatric Association -- described the bill as "disruptive" and "harmful" to patients.
In addition to failing to preserve the coverage and consumer protections enacted by the ACA, the groups said the new bill "would create a health care system built on state-by-state variability that would exacerbate inequities in coverage and most likely place millions of vulnerable individuals at risk of losing their health care coverage."
The groups continued to urge Congress to pursue "regular order" including hearings, debates, and committee markups and not to rush a vote.
Hospitals Disappointed
Because the new bill's approach is similar to previous repeal proposal's, Bruce Siegel, MD, MPH, the president and CEO of America's Essential Hospitals, said he anticipates a similar result: "millions of Americans losing coverage. "
"Unlike those previous proposals, the Graham-Cassidy bill provides no meaningful relief from looming cuts to Medicaid disproportionate share hospital (DSH) payments," he noted, while stressing that the new bill would also limit "how states raise support for the safety net."
"Rather than providing flexibility, this would limit states' coverage and financing choices," he said.
Similarly, "This proposal would erode key protections for patients and consumers and does nothing to stabilize the insurance market now or in the long term," said Rick Pollack, CEO of the American Hospital Association, in a press statement.
On Board, On the Fence
Not all physicans want to see the bill shredded.
Despite her "mixed feelings," Jane Orient, MD, executive director of the Association of American Physicians and Surgeons, said on the whole, "I think that it may in the long-term make things a tiny bit better by permitting a wedge of freedom."
Examples of this freedom include giving block grants to states and rolling back federal regulation so that states can experiment and make their Medicaid programs more efficient.
"The idea that we can just infinitely expand the money that we're pouring into Medicaid is going to come to a halt. It has to. How can you keep spending money that you don't have?" Orient asked.
Half of all Medicaid funding is money coming from creditors, because the government has to borrow 50 cents of every dollar it spends, she said.
The American Association of Neurological Surgeons/Congress of Neurological Surgeons indicated that members like giving states more control over how healthcare dollars are spent, and repeal of the medical device tax. But the group is concerned about "backsliding" on other insurance reforms, such as those involving pre-existing conditions, a press representative told MedPage Today in a phone call.
"Without a [Congressional Budget Office] score, it's impossible to predict what the states are going to do at this point," the representative said. No CBO analysis of the bill other than its effect on the federal budget is expected.
Other specialty groups have remained silent on the bill.
Insurers Skeptical
Another important set of stakeholders also stated opposition to Graham-Cassidy: the health insurance industry, whose chief trade group declared it "cannot support this proposal."
Marilyn Tavenner, CEO of America's Health Insurance Plans, outlined six "guiding principles" in a letter to McConnell and Schumer on Wednesday. They included: stabilizing the individual insurance market, a strong Medicaid program, guaranteed coverage for all, sufficient lead time to implement reforms smoothly, improved affordability, and reliance on the private market.
"The Graham-Cassidy-Heller-Johnson proposal fails to meet these guiding principles," the letter said, "and would have real consequences on consumers and patients by further destabilizing the individual market; cutting Medicaid; pulling back on protections for pre-existing conditions; not ending taxes on health insurance premiums and benefits; and potentially allowing government-controlled, single payer health care to grow."
Senate leadership aims to bring the bill to the floor for a vote next week. The body faces a Sept. 30 deadline to pass legislation with budgetary implications without needing 60 votes to overcome a filibuster.
WASHINGTON -- A group of Republican senators introduced a bill Wednesday to repeal and replace the Affordable Care Act (ACA) as the timeline for getting such a bill passed this year continues to wind down.
The yet-to-be-named measure, introduced by senators Bill Cassidy, MD (R-La.), Lindsey Graham (R-S.C.), Dean Heller (R-Nev.), and Ron Johnson (R-Wis.) would give money annually to states in the form of a block grant, which could be used "to help individuals pay for healthcare," Cassidy's office said in a press release posted on the senator's website.
"This proposal removes the decisions from Washington and gives states significant latitude over how the dollars are used to best take care of the unique health care needs of the patients in each state," the press release stated. "The grant dollars would replace the federal money currently being spent on Medicaid expansion, Obamacare tax credits, cost-sharing reduction (CSR) subsidies and the basic health plan dollars."
The amount of money each state would receive is based on a complicated formula which starts with the amount of money each state receives from Medicaid expansion, ACA tax credits, CSR subsidies, and basic health plan funds. "By 2026, at base rate, every state will be receiving the same amount of money for each beneficiary in the 50-138% federal poverty level range," according to an FAQ on Cassidy's website. "This ensures that high-spending states and low-spending states come to parity at the end of the time frame."
The measure would also repeal the ACA's individual and employer mandates as well as its medical device tax, and would "strengthen the ability for states to waive Obamacare regulations," the release continued. It also would "protect patients with pre-existing medical conditions."
The American College of Physicians (ACP) opposed the bill. "We believe that the substantial cuts to Medicaid authorized by this legislation would cause a significant increase in the number of uninsured patients and that it would undermine essential benefits provided for patients insured under current law," Jack Ende, MD, president of the ACP, wrote in a letter to Graham and Cassidy.
"We urge you to set aside this legislation and instead allow the Senate to consider any improvements to the ACA, through a more deliberative process of regular order, in which hearings are held to solicit the advice of health care experts and stakeholders, with any such improvements considered in a bipartisan manner in which both parties may offer amendments."
In addition, Ende said, the ACP is concerned that the funding formula outlined in the legislation "provides less funding than currently in place for individuals to purchase health insurance in the individual market and that states could use these funds for a broad range of health care purposes, not just coverage, with essentially no guardrails or standards to ensure affordable, meaningful coverage."
Planned Parenthood, whose funding would be zeroed out under the bill, also announced its opposition. "The Graham-Cassidy-Heller proposal is the worst ACA repeal bill yet, and it is especially terrible for women," Dawn Laguens, executive vice president at Planned Parenthood Federation of America, said in a statement.
"It blocks women from getting preventive care at Planned Parenthood. It slashes Medicaid, which 1 in 5 women of reproductive age rely on for care, including birth control and cancer screenings. It guts essential health benefit protections, including maternity coverage and prescription drugs. Thirteen million women could lose coverage to maternity care under this bill. And it raises premiums on millions more by eliminating tax credits."
The bill does have one important supporter: President Trump. "I applaud the Senate for continuing to work toward a solution to relieve the disastrous Obamacare burden on the American people," Trump said in a statement. "Obamacare has been a complete nightmare for the many Americans who have been devastated by its skyrocketing healthcare premiums and deductibles and canceled or shrinking plans. As I have continued to say, inaction is not an option, and I sincerely hope that Senators Graham and Cassidy have found a way to address the Obamacare crisis."
The senators face a very narrow window of time to get the bill passed, since the authority to use the budget reconciliation process -- which would allow the bill to pass with only 50 votes -- expires on Sept. 30th; after that, 60 votes would likely be needed for passage. To meet that Sept. 30 deadline, they would have to get the bill passed by all the relevant committees, scored by the Congressional Budget Office, and put on the Senate floor for a vote, all within about 2.5 weeks.
In the meantime, there was also other healthcare action Wednesday as Sen. Bernie Sanders (I-Vt.) introduced his single-payer bill, which would transition all Americans to a government-run "Medicare for all"-type system.
"I know taking on the insurance companies and the drug companies and Wall Street ... and all those people who profit off our dysfunctional healthcare system will not be an easy fight," Sanders said in a video posted on his website. "The only way we win this is when the American people stand up -- as they are -- and demand real change ... Let us go forward and finally do what this country should have done a long time ago and that is to guarantee healthcare for all people."
Sanders' bill, which has virtually no chance of passage with a Republican-controlled Congress and White House, nonetheless has 15 Democratic senators who have signed on as co-sponsors.
And in another ACA-related move, representatives Michael Burgess, MD (R-Texas), and Pat Tiberi (R-Ohio) introduced a bill Tuesday to repeal the ACA's individual mandate. "The individual mandate is forcing Americans to purchase plans they don't want, don't need, and can't afford to use," Tiberi said in a statement. "This legislation would provide relief to Americans who are trapped in overpriced and unreliable Obamacare plans and eliminate the threat of an unfair fine from the IRS."
Senators were mostly in harmony on suggestions for shoring up the health insurance marketplaces through a reinsurance program and keeping cost-sharing reduction payments.
This article first appeared September 06, 2017 on Medpage Today.
WASHINGTON -- Wednesday's Senate hearing on how to stabilize the Affordable Care Act's (ACA) health insurance marketplaces was notable for its almost total agreement on solutions -- and not just among the senators.
Making sure the cost-sharing reduction (CSR) payments are continued "is the most critical issue you can address to assure market stabilization in 2018," Tennessee insurance commissioner Julie McPeak told the Senate Health, Education, Labor, & Pensions (HELP) Committee; she was referring to money the federal government gives insurers to help low-income enrollees with their copayments and deductibles. "Beyond [that], the government should establish a reinsurance mechanism" so insurers won't be on the hook for very high-cost patients.
"You must permanently fund the CSR payments; that's going to help a great deal," said Washington state insurance commissioner Mike Kreidler. As for reinsurance, "it worked well in the state of Washington for the first 3 years that we had a reinsurance program; we'd like to see it go forward."
"CSRs are the right way to go ahead unless we make other dramatic changes in the future," said Oklahoma insurance commissioner John Doak.
Senators in Harmony -- Mostly
For the most part, senators on both sides of the aisle agreed with them. Appropriating the CSR payments through the end of 2018 will help to "limit increases in premiums in 2018... make certain that health insurance is available in every market, and lay the groundwork for future premium decreases," said HELP Committee chairman Lamar Alexander (R-Tenn.). He also urged support for making 1332 waivers -- which states can use to make changes to their marketplace programs -- more flexible, so states can design programs to meet their unique needs.
"We ought to be able to take this small, limited bipartisan step on health insurance, and if we don't, millions of Americans will be hurt," he said.
"Should these out-of-pocket cost reductions be discontinued, independent analysis suggests that premiums could be an average of 20% higher next year for the most popular plans on the exchanges," said HELP Committee ranking member Patty Murray (D-Wash.). "There will be even more uncertainty in the markets -- and patients and families will likely have fewer options when they go to pick their plans. That's unacceptable and it is avoidable."
That is not to say there was no dissent at the hearing. "We're subsidizing an individual market that does not work," said Sen. Rand Paul (R-Ky.). "Can you fix it, and is it morally and ethically right to take money from taxpayers and give it to insurance companies to subsidize people in the individual market?"
Instead of keeping people in that market, "we should try to figure how to get people into the part of the marketplace that's working," such as the market for large-group self-insured plans, which comprise 36% of the overall health insurance market. "It's probably working better than anything else ... It probably has the lowest increase in rates over time, and they have cheaper prices."
Paul gave the example of the nation's 15 million fast-food workers -- low-income people who are struggling to make ends meet. "These are people we should want to help," he said. Let's let them become part of [self-insured] plans; let's have nationwide health associations ... It would cost the taxpayer nothing. Let's let people associate with other people to buy insurance and get the heck out of the individual market."
Simplifying Waivers
The insurance commissioners also had other suggestions for shoring up the marketplaces. For example, Pennsylvania insurance commissioner Teresa Miller commented that under current law, states that apply for a 1332 waiver must make sure it will be budget neutral, and they must also do the same with 1115 waivers, which deal with state Medicaid programs. "Being able to think about waivers together rather than separately and having overall budget neutrality looked at as a pool ... would allow states to be more innovative."
The 1332 waiver process also could be streamlined, said Alaska insurance commissioner Lori Wing-Heier. "The [1332 waiver] process is somewhat onerous in the fact that there's not a defined application to submit, so states applying are hoping they're supplying data requested by CMS [the Centers for Medicare & Medicaid Services]."
"After that is done, the part that is stifling the states is a 6-month waiting period before we receive final approval," she continued. "The first part of application can be done in ... a couple of months, but then we wait for up to 6 months to see if we received final approval to be funded. I will tell you that CMS was very helpful to us, but it's still a rather lengthy process."
The commissioners had mixed opinions on the value of the health insurance "navigators" hired to help consumers sort through their insurance options and choose a plan. "I think the Navigator program needs some oversight," Doak said. "I would ask the full Senate committee to do an audit of Navigator program to find out whether they are they doing the job they're supposed to be doing."
Instead of using Navigators, "I feel [the enrollment process] should be done by licensed [insurance] brokers," Doak said. "I've been in every county in Oklahoma and ...[there is an] insurance agent on every corner."
But Wing-Heier, of Alaska, disagreed. "We rely on Navigators for enrollment for people in rural Alaska," she said.
The 40% cut to Navigator funding proposed by the Trump administration "would be devastating for our population," she said. "There is also a part that's very cultural in Alaska in that we have a variety of languages. Navigators are able to cross that bridge; they provide that service. We don't have that very readily in the insurance community."
Short Timeline for Action
As the hearing drew to a close, Alexander said it had been very helpful. "I heard three things: reinsurance, CSRs, and more flexibility with 1332 [waivers]," he said, adding that once the current issue of shoring up the marketplace is attended to, "we should be doing more on larger question of addressing healthcare costs."
"We should be looking at what we pay to visit the hospital, what we spend on prescription drugs, and how much excessive paperwork increases our costs, and what should be done to encourage wellness. We should be looking at real ways to bring down the cost of healthcare, which is the easiest way to reduce the cost of health insurance."
When the hearing began, Alexander said his plan was to get consensus on a bill by the end of next week, after the committee finishes three more hearings on this topic, so Congress can act on it by the end of the month, when insurers need to make their final decisions for 2018. Because of the short time remaining to craft a solution, "we're moving at such a rapid pace we'll have to make a recommendation to the full Senate and hopefully come up with something [that enough of them] will support," Alexander told reporters after the hearing ended.
A physician who attended the hearing also praised the outcome. "I think it's amazing we finally had a bipartisan discussion about healthcare," said Kevin Burns, MD, a family physician in Tucson, Ariz.
He praised a suggestion made at the hearing that consumers living in hard-to-insure areas be given the option of buying into the federal employees' health benefits plan. "That would be a very [useful] option to provide more access to insurance," he said.
The 2.3% sales tax applies to all medical devices. It was suspended in 2016 and 2017. Now their manufacturers are hoping for a permanent repeal.
This article first appeared August 31, 2017 on Medpage Today.
By Joyce Frieden
WASHINGTON -- When Congress returns next week from its August recess, its "to-do" list will likely include repeal of the Affordable Care Act's (ACA's) unpopular tax on medical devices, although how high it will be on that list isn't clear.
The 2.3% sales tax -- collected in 2013, 2014, and 2015, but not in 2016 or 2017 when Congress voted to suspend it temporarily -- applies to all medical devices. Now their manufacturers are hoping for a permanent repeal.
"We've been working on many levels -- in the districts, in the states, to make sure device tax repeal remains a Tier 1 priority," said Greg Crist, a spokesman for AdvaMed, the device industry trade group, in a phone interview. But, "there are a lot of competing elements with only 12 legislative days in September," he said, citing Hurricane Harvey relief and a looming deadline to raise the federal death ceiling as other issues Congress must deal with. "When they come back, timing will be critical."
The repeal proposal does have at least one thing going for it: bipartisan support. "If you put it on the floor of the House and Senate tomorrow, it would pass overwhelmingly; it's overwhelmingly bipartisan," Crist said. "What clouded the case for the last few months was politicization around the Obamacare repeal effort." Supporters run the political gamut from Republicans including senators Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) to Democratic senators Elizabeth Warren (D-Mass.) and Al Franken (D-Minn.), both of whom have many device manufacturers in their states.
Why repeal the device tax? "The medical device tax is not only counter-productive but punitive," Grace-Marie Turner, president of the Galen Institute, a right-leaning think tank in Alexandria, Va., said in an email. "The costs of the tax ultimately are passed along to consumers, raising the costs of their health insurance. And the medical device tax also stifles innovation in one of the most vibrant and important industries in the country, also suppressing job creation. It has to go."
The Galen Institute was one of 36 conservative groups that sent a letter earlier this month to House Speaker Paul Ryan (R-Wis.) and Senate Majority Leader Mitch McConnell (R-Ky.) supporting device tax repeal. "If Congress allows it to go into effect in 2018, the medical device tax could lead to more than 25,000 lost jobs by 2021," the letter said, citing research by Robert Book, PhD, a conservative health economist. "Over the next decade, this excise tax is projected to increase taxes by $30 billion."
Repealing the tax would cost the government a little less than $20 billion over 10 years, Crist said. As to how that money should be made up, "We certainly want to work with leaders to address that," but he noted that the tax wasn't "going to fund further research and development for the device community; it was strictly a 'pay-for'" -- that is, a general revenue enhancement.
The tax does have a supporters. Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities, a left-leaning think tank here, argued in a 2015 blog post that the tax would not hurt medical device innovation. "To the contrary, health reform may well spur medical device innovation by promoting more cost-effective ways of delivering care," he wrote.
In addition, "the tax will not have much effect on employment, as a careful economic analysis by the Congressional Research Service finds," he continued. "In fact, by extending health coverage to many more Americans, health reform will increase the demand for medical devices and device manufacturers' revenue. A study by Wells Fargo Securities finds that health reform will increase device sales by 3.6% over its first decade."
AdvaMed, for its part, noted earlier this year that the industry had lost 29,000 jobs during the years that the tax was in effect, citing data from the Commerce Department.
There also remains the possibility of simply continuing the tax's temporary suspension for another year. "When you look at Congress, it is much more likely to kick the can down the road than make a permanent change," Elizabeth Carpenter, senior vice president at Avalere, a healthcare consulting firm here, said in a phone interview. "Certainly, a 1-year extension [of the delay] comes with a lower price tag and satisfies the device industry for the time being."
Although it would be possible to pass a repeal or delay bill as a stand-alone measure, it's not very likely, according to Crist. "While it is possible, and it would pass because the votes are there, just finding the floor time for a singular bill such as that this late in the year makes a stand-alone very difficult to call to the floor," he said in an email.
Which then raises the question of what other bill it might be attached to. "There are certainly a number of potential vehicles this fall where not just the device industry but other industries across the healthcare system are looking to advance their priorities, whether it's a package that includes a debt limit increase, funding the government, or CHIP [Children's Health Insurance Program] reauthorization," said Carpenter.
However, members of Congress have argued that some of those other bills, such as the CHIP reauthorization, should be "clean," with nothing else attached to them. "That is the question with a number of potential vehicles -- is the debt limit increase clean? Is the CHIP reauthorization clean?" she said. "All of those must face their own unique political circumstance, and it's too soon to tell how they all will come together."