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The Centers for Medicare & Medicaid Services (CMS) has announced a deadline extension, along with several exceptions from reporting requirements for primary care providers and other healthcare professionals participating in Medicare quality reporting programs. The changes affect upcoming measure reporting and data submission for those programs. CMS is taking these steps in an effort to provide relief for providers during the current COVID-19 pandemic.
CMS states that it is taking actions to assist the “clinicians, providers, and facilities participating in Medicare quality reporting programs including the 1.2 million clinicians in the Quality Payment Program and on the front lines of America’s fight against the 2019 Novel Coronavirus (COVID-19).” CMS Administrator Seema Verma says, “In granting these exceptions and extensions, CMS is supporting clinicians fighting Coronavirus on the front lines.”
The deadline for 2019 data submission for the Quality Payment Program (QPP) – Merit-based Incentive Payment System (MIPS) has been extended from March 31, 2020 to April 30, 2020. In addition, MIPS eligible providers who do not submit MIPS data by the new deadline will qualify for the automatic extreme and uncontrollable circumstances policy and will receive a neutral payment adjustment for the 2021 MIPS payment year.
Primary care providers are included in the MIPS option of the QPP if they are an eligible clinician type and meet the low volume threshold, which is based on allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) and the number of Medicare Part B patients who are furnished covered professional services under the Medicare Physician Fee Schedule.
MIPS performance is measured through the data clinicians report in four areas:
The CMS announcement also stated that:
CMS recognizes the burden placed on providers who are responding to the COVID-19 pandemic, in having to also focus on data collection and reporting for MIPS. The agency also acknowledges that the numbers may be somewhat skewed during a time of national emergency, particularly in regard to cost, readmissions, and patient experience. Quality measure data collection and reporting during the pandemic may not be reflective of the provider’s true performance and CMS seeks to hold healthcare organizations harmless for not submitting data during this time.
Going forward, CMS has indicated it will continue to monitor the COVID-19 situation. Healthcare providers must focus on caring for patients first and foremost so additional options will be assessed for offering additional relief to primary care providers and their staff during the emergency period.
Janie Feldsher March 30, 2020Read
Senator Bernie Sanders (D-Vermont) is a candidate in the 2020 presidential election and a proponent of a one-payer healthcare program. Specifically, Sanders introduced a bill in the Senate and includes a plan in his campaign that has been labeled Medicare for All. Although credited with the term and with the initiative, it was actually Republican Senator Jacob Javits who proposed expanding Medicare to cover all Americans in 1970 through a program he called “Medicare for all.”
The program Sanders has proposed is somewhat different from that submitted by Javits and actually expands the concept of Medicare as it exists today. The senator cites the fact that medical bills are the primary cause of bankruptcy for Americans and that people need a healthcare program that will cover more, if not all, of their expenses while ensuring they receive the highest quality care. Sanders states that “We should be spending money on doctors, nurses, mental health specialists, dentists, and other professionals who provide services to people and improve their lives.”
The Sanders platform states that the way to reduce costs and to refocus payments, away from private insurance and giant pharmaceutical companies, is by “Joining every other major country on Earth and guaranteeing health care to all people as a right, not a privilege, through a Medicare-for-all, single-payer program.” His plan would virtually eliminate private insurance and replace it with the expanded government-sponsored program.
The Washington Times reports that the Medicare for All program proposed by Sanders “would cover all U.S. residents, including illegal immigrants. It would pay for doctor and hospital visits, prescription drugs, dental and vision services, and long-term care. Private insurance would be allowed, but only as a supplement.” Many of those services, including dental and vision, are not now covered under basic Medicare plans.
Medicare for All, as proposed by Sanders, would also focus on the affordability of prescription drugs specifically. His plan would:
Janie Feldsher March 2, 2020Read
Biometrics are gathered to digitally identify individuals, based on unique physical characteristics. Biometrics include fingerprints, facial features, voice cadence, and other identifiers. The US Department of Homeland Security uses biometrics primarily for immigration purposes, vetting and credentialing, detecting illegal entry attempts, and verifying visa applications. In healthcare, biometrics are used to identify patients and to ensure that employees have access only to the information they need to know.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required HHS to adopt national standards for electronic health care transactions and code sets, unique health identifiers, and security. In 2009, as part of the American Recovery and Reinvestment Act (ARRA), the Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law. The HITECH Act addresses the privacy and security concerns associated with the electronic transmission of protected health information.
As the use of biometrics becomes more prevalent in healthcare, providers must exercise care in regard to adhering to the regulations of HIPAA and the HITECH Act. Biometrics are in the category of protected health information (PHI) and as such, healthcare providers must ensure that appropriate safeguards are put in place to protect the confidentiality and integrity of the information.
Illinois was the first state to recognize the importance of protecting data gathered through biometrics. In 2008, the state passed the Biometric Information Privacy Act (BIPA), which applies to healthcare, hospitality, retail, and any employer who uses fingerprint technology. Many businesses use employees’ fingerprints, for example, for timekeeping purposes.
BIPA requires healthcare providers to, in most instances:
Following the example set in Illinois, five other states – Texas, Washington, California, New York, and Arkansas – have passed similar biometric statutes. The California Consumer Privacy Act (CCPA), which will go into effect in 2020, defines biometric data as “physiological, biological or behavioral characteristics, including … DNA[,] that can be used … to establish individual identity,” which includes “sleep, health, or exercise data that contain identifying information.”
Given the definitions of HIPAA, the HITECH Act, and biometrics as they are used in healthcare, there is a risk involved in collecting and maintaining this data. As with all PHI, steps must be taken to ensure the security and integrity of biometrics when used in a healthcare setting to comply with federal regulations and to provide patients with appropriate data safeguards.
Janie Feldsher February 19, 2020Read
Many factors went into the development of the Centers for Medicare and Medicaid Services (CMS) Primary Cares Initiative, including a concern for patient healthcare outcomes, a need to reduce healthcare costs, and a focus on reducing hospitalizations. Based on the previous Comprehensive Primary Care (CPC) models, the new initiative includes five models developed by the Center for Medicare and Medicaid Innovation (CMMI) with input from physicians and organizations such as the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA).
CPC models were launched in October 2012 as a “a four-year multi-payer initiative designed to strengthen primary care.” CPC was the foundation of a five-year initiative, Comprehensive Primary Care Plus (CPC+), “a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation.” Each of these initiatives offered various levels of physician participation, based on different payment models. The original CPC initiative concluded in 2016.
CPC+ was launched in January 2017, integrating “lessons learned from CPC, including insights on practice readiness, the progression of care delivery redesign, actionable performance-based incentives, necessary health information technology, and claims data sharing with practices.” CPC+ included three payment elements: Care Management Fee (CMF); Performance-Based Incentive Payment; and Payment under the Medicare Physician Fee Schedule, with two track options.
The latest initiatives were developed by CMMI with input from stakeholders and a focus on the need to improve primary care outcomes that will reduce hospitalization rates for Medicare recipients. When announcing the CMS Primary Cares Initiative, CMS Administrator Seema Verma referenced the financial state of what is commonly known as Medicare Part A. Essentially, the Social Security Board of Trustees reported “that the Hospital Insurance (HI) Trust Fund portion—otherwise known as Medicare Part A—will be depleted in 2026, the same year projected in last year’s report. Revenues will be enough to pay 89% of HI costs.”
In regard to the CMS Primary Cares Initiative, U.S. Department of Health and Human Services (HHS) Secretary Alex Azar stated that “For years, policymakers have talked about building an American healthcare system that focuses on primary care, pays for value, and places the patient at the center. These new models represent the biggest step ever taken toward that vision.” He added, “these models will test out paying for health and outcomes rather than procedures on a much larger scale than ever before.”
Janie Feldsher January 21, 2020Read
The number of ACO contracts has decreased slightly, but the number of individuals covered by those ACOs has increased from 2018 to 2019. The Centers for Medicare & Medicaid Services (CMS) recently released data on Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs) for Performance Year 2019 that show some changes in provider participation as of July 1, 2019. Experts writing for Health Affairs analyzed the results of the report, gauging the level of ACO success during the reporting period.
MSSP “facilitates coordination among providers to improve the quality of care for Medicare fee-for-service beneficiaries while reducing the growth in health care costs. Eligible providers, hospitals, and suppliers may apply to participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO).” In addition, CMS has created a new ACO program, Pathways to Success, which may also have impacted the success of ACOs in 2019.
The Health Affairs analysts state that there has been an increase in the number of physician-led ACOs “and they have moved to downside risk at a slightly higher rate than ACOs with hospitals.” The total number of ACOs has decreased while the number of lives impacted has increased during the performance year. Of the 995 ACOs currently active, 425 (43 percent) are physician-led, compared to 274 hospital-led and 294 jointly led.
Previous estimates speculated that about half of ACOs would exit MSSP, the largest ACO program, with the rollout of the Pathways to Success program. However, in reality only a modest number left and 41 ACOs joined the program in July 2019. Higher dropout rates were noted for physician-led ACOs than for hospital-led and large ACOs.
Health Affairs also reports that “so far this year in 2019, there was a modest decrease in the proportion of downside risk contacts by small organizations, and conversely there was a modest increase in proportion of downside risk contacts by large organizations.” The analysts stated that “The acceleration of ACOs accepting downside risk beginning in 2019 could represent the MSSP policy changes taking effect and deterring smaller organizations from joining or staying based on mandatory downside risk.”
Tyler Comstock December 9, 2019Read
The Stark Law, named after Rep. Pete Stark, a Democrat from California, was originally enacted in 1989 with the basic premise of not allowing physicians to refer Medicare or Medicaid patients to healthcare services from which the physician or a member of the physician’s family would profit financially. Over the years, additional regulations and exceptions were added to the Stark Law and it eventually became a vast collection of regulations and statutes.
The idea behind the original concept was to keep physicians from sending patients for unnecessary tests or healthcare services and driving up healthcare costs. In October 2019, given the current shift to value-based care and away from the fee-for-service model, the Centers for Medicare & Medicaid Services (CMS) proposed a new ruling that would “modernize and clarify the regulations that interpret the Medicare physician self-referral law,” or the Stark Law.
CMS published a Request for Information (RFI) in June 2018, soliciting input on addressing regulatory barriers to a value-based healthcare payment and delivery system under the Stark Law. The responses they received indicated that “regulations have not kept up with the evolution of a healthcare landscape that is focused more on value than volume.” Comments included requests for “additional guidance on fundamental requirements and other changes to help ease burden and make compliance more straightforward.”
As a result, CMS is now proposing a rule that would “create new, permanent exceptions to the Stark Law for value-based arrangements.” With today’s healthcare environment, industry stakeholders are now saying that “because the consequences of noncompliance with the Stark Law are so dire, physicians and other healthcare providers may be discouraged from entering into innovative arrangements that would improve quality outcomes, produce health system efficiencies, and lower costs (or slow their rate of growth).”
CMS states that revisions to the Stark Law that are based on the changing value-based healthcare environment “would unleash innovation by permitting physicians and other healthcare providers to design and enter into value-based arrangements without fear that legitimate activities to coordinate and improve the quality of care for patients and lower costs would violate the Stark Law.”
Tyler Comstock November 1, 2019Read
Healthcare is the main focus of presidential candidates, the media, and technology advocates. Today’s healthcare landscape can be complicated, with many elements for the independent physician to keep up with and to be in compliance with, depending on the provider’s situation. Those independent physicians who care for Medicare patients must know the latest updates from the Centers for Medicare & Medicaid Services (CMS). Providers with younger patients need to understand the healthcare preferences of Millennials and Generation Zers. Rising healthcare costs impact all independent physicians.
Today’s healthcare landscape includes:
Campaigns for Medicare for All and other variations of one-payer healthcare plans. Presidential candidates are promoting their own versions of government-sponsored programs, ranging from an all-inclusive, expanded Medicare program, to public options that complement private insurance and the programs covered under the Affordable Care Act (ACA).
Technology advances. Telehealth and other virtual healthcare services are becoming more accepted and more commonly used as alternatives to the traditional office visit. Even CMS is “finalizing changes that would allow Medicare Advantage beneficiaries to access additional telehealth benefits, starting in plan year 2020.” In addition, the electronic health record (EHR) is advancing in capabilities, including interoperability, which is key to the physician’s ability to coordinate a patient’s care with other providers.
Adjusting to changing preferences. Speed, convenience, and available technology are the primary concerns for Millennials, particularly in regard to how they access healthcare. Independent physicians who offer the ability to communicate electronically, to access telehealth services, and to make appointments online or through an app will be more attractive to that busy age group.
Prescription drug prices are a topic of major concern. In a research study conducted by the Scripps Research Translational Institute, five years of pharmacy claims (from 2012 to 2017) were analyzed. The study included 49 brand-name drugs that had more than 100,000 total claims each. As reported by NBC News, “All but one of the drugs included in the study saw regular annual or biannual cost increases. The cost of 36 of the drugs increased over the six-year period by more than 50 percent, and the cost of 16 more than doubled. Overall, the median cost of the drugs included in the study increased 76 percent.”
Tyler Comstock October 17, 2019Read
In July 2019, the Centers for Medicare & Medicaid Services (CMS) issued its Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020. The new policies will take effect January 1, 2020. The proposed rule includes “proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS).”
Among the changes and updates proposed in the 2020 Physician Fee Schedule (PFS) are several adjustments in codes and payment rates:
CY 2020 PFS Rate setting and Conversion Factor
Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice. They become payments rate after a conversion factor is applied. Those payment rates include an overall payment update specified by statute. The proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.
Medicare Telehealth Services
The following codes are proposed for the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.
Payment for Evaluation and Management (E/M) Services
The proposed PFS consolidates the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care that was finalized in the CY 2019 PFS final rule for implementation in CY 2021 into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.
Care Management Services
A number of the Chronic Care Management (CCM) services codes are proposed to be replaced with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time. Physicians involved in CCM provide care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period.
Medicare Shared Savings Program (MSSP)
As part of the PFS proposed rule, CMS is soliciting comment on how to potentially align the Medicare Shared Savings Program (MSSP) quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology, recognizing that accountable care organizations (ACOs) and their participating providers and suppliers dedicate resources to performing well on quality metrics. The goal is to align quality metrics across programs that will reduce burden and will allow ACOs to more effectively target their resources toward improving care.
Tyler Comstock September 20, 2019Read
The Centers for Medicare & Medicaid Services (CMS) announced changes to the Merit-based Incentive Payment System (MIPS) on July 29, 2019, that are intended to streamline the Quality Payment Program (QPP). CMS is focused on reducing administrative burden for healthcare providers with its new pay-for-performance program called the MIPS Value Pathways (MVP). In the same announcement, CMS included updates to the Medicare Physician Fee Schedule (PFS) effective January 1, 2020.
One of the goals of the updated policies is to help physicians who care for chronically ill patients. CMS Administrator Seema Verma states that “Today one in five Medicare beneficiaries have multiple chronic diseases.” The proposed rule for 2020 “would increase payments to practitioners for time spent on care management after a patient leaves the hospital ensuring proper follow-up and continuity of care for patients.” In addition, CMS is proposing, for the first time, “to pay for care management services for patients with a single, high-risk chronic condition such as diabetes or high blood pressure.” Under the new rule, physicians would also be paid for “additional time spent on care management activities for patients suffering from multiple chronic conditions.”
The new MVP program would begin in the 2021 performance period, moving MIPS “from its current state, which requires clinicians to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities, to a system in which clinicians will report much less. Under MVPs, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs) – new approaches to paying for care through Medicare that incentivize quality and value.”
CMS’s proposed rule includes:
The public is invited to comment on the CY 2020 Physician Fee Schedule proposed rule and the CY 2020 Quality Payment Program proposed rule. Comments must be received within the 60-day comment period, which closes on September 27, 2019. When commenting refer to file code: CMS-1715-P.
Tyler Comstock August 26, 2019Read
When Medicare was created in 1965, it was intended to eventually cover all Americans as a universal healthcare plan, not to remain as an insurance program exclusively for the elderly. In 1972, minor changes were made to Medicare eligibility, including as recipients those with disabilities and with end-stage renal disease. The idea of a national health insurance plan was also re-introduced in the early 1970s but was defeated each time it was proposed. Republican Senator Jacob Javits proposed expanding Medicare to cover all Americans in 1970 and was the first one credited to have coined the phrase “Medicare for all.”
From 2003 to 2017, Democratic Representative John Conyers introduced and reintroduced his Expanded and Improved Medicare for All Act. In 2006, Democratic Senator Ted Kennedy introduced a Medicare for All Act, which proposed the idea that was the original intent of the Social Security Administration staffers who set up Medicare, to gradually expand Medicare to include all citizens and legal residents.
In recent years, “Medicare for all” has re-emerged in political campaigns. Today, the concept refers to a single-payer type of health insurance that would virtually eliminate private health insurance or exist alongside private insurance, depending on the proposal.
Various versions of the universal healthcare concept are being proposed. Essentially the idea of “Medicare for all” includes the basic healthcare benefits of the current Medicare system such as provider visits, certain outpatient services, and hospitalization. Some proposals expand that coverage to include dental, vision, hearing, and long-term care services with no premiums, deductibles, or co-pays. Other proposals include a “public option” that would not eliminate private insurance but would be considered a “government insurance plan” offered as an option to those seeking health insurance.
“Medicare for all” is sometimes referred to as “single payer” or “universal” healthcare. Single-payer means that there would only be one payer for the cost of the universal health coverage and that would be the federal government. Taxes would probably increase to cover part of the costs, but how much and who would be taxed are also issues up for debate.
Medicare coverage for all Americans would ensure that everyone in the country has healthcare coverage, a concept that has been embraced by every wealthy, developed nation except the US. With rising healthcare costs, including the costs of health insurance, one in ten Americans is uninsured today and many of those with insurance are challenged financially by their medical bills.
Tyler Comstock August 14, 2019Read