Pending changes to MACRA

The reporting requirements for participating in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) can be an overwhelming burden for independent physicians. The Centers for Medicare & Medicaid Services (CMS) has acknowledged that burden and is considering changes to MACRA that would continue to emphasize quality care while improving the reporting processing for independent physicians.

CMS received a significant number of responses from providers when they published several requests for information (RFIs) recently. According to the Healthcare Financial Management Association (HFMA), the agency is “is looking at overhauling MACRA—including through simplification of the data submission process—as authorized by the Bipartisan Budget Act of 2018 (BBA).” CMS is reviewing each quality measure that independent physicians are required to report as part of MACRA.

Kate Goodrich, MD, director of the Center for Clinical Standards and Quality and CMO for CMS, stated that the agency is also working with electronic health record (EHR) vendors to help ease the reporting requirement burdens for independent physicians. Specifically, the agency is stressing the need to automatically extract data from the EHRs to submit to CMS, which would require little to no action on the part of independent physicians.

Goodrich emphasized, though, that there will be no more delays in the rule implementation for providers to adopt the 2015-edition EHR technology to meet the requirements of the EHR meaningful use programs. She stated that CMS has “delayed this a couple years, but last year we finalized that this would be required starting in 2019; we are not backing down on that, so we are not changing that and will reiterate that.”

Additionally, CMS is planning to offer more alternative payment models (APMs) in 2018. The agency is emphasizing physician enrollment in the new Bundled Payments for Care Improvement Advanced (BPCIA) program, CMS’s latest push on APMs. Starting in 2019, independent physicians who enroll in the BPCIA program will qualify as advanced APMs under MACRA.

Sam Peirce
May 8, 2018


CMS to allow patients to bill physicians directly

The Centers for Medicare & Medicaid Services (CMS) has released comments it received on the CMS Innovation Center’s New Direction Request for Information (RFI) published in the fall of 2017. The intent of the RFI was to “collect ideas on a new direction for the agency’s Innovation Center to promote patient-centered care and test market driven reforms that: empower beneficiaries as consumers, provide price transparency, increase choices and competition to drive quality, reduce costs, and improve outcomes.”

Many of the comments CMS received from healthcare providers “reflected broad support for reducing burdensome requirements and unnecessary regulations.” To that end, CMS has announced that it is taking steps toward developing a direct provider contracting model. Under the new structure, Medicare patients would be able to contract directly with their physicians.

In their announcement, CMS indicated that the new direct provider contract model would drive better beneficiary outcomes by allowing physicians to “take further accountability for the cost and quality of a designated population.” In addition, the model would potentially “enhance the doctor-patient relationship by eliminating administrative burden for clinicians and providing increased flexibility to provide the high-quality care that is most appropriate for their patients, thus improving quality while reducing expenditures.”

CMS Administrator Seema Verma has said that she recognizes that “the best ideas don’t come from Washington, so it’s important that we hear from the front lines of our healthcare system about how we can improve care.”

A follow-up RFI has been issued, to gather detailed information from healthcare providers that will enable CMS to design and release the direct provider contract model. Comments on the recently issued RFI are due by 11:59 EDT on Friday, May 25, 2018. Physicians interested in providing input can find the Direct Provider Contracting RFI at

Sam Peirce
April 25, 2018


CMS shares plan for advancing value-based care and interoperability

Focusing on the patient’s needs is paramount for value-based care to truly be effective. That was a significant point delivered by CMS Administrator Seema Verma at the HIMSS18 Conference in March 2018. In addition to discussing interoperability and technological advances, Verma said, “I’ve always been struck by how seldom the patient is mentioned in discussions around value-based care. Let me be clear, we will not achieve value-based care until we put the patient at the center of our healthcare system.”

Interoperability plays a huge role in enabling patients to be at the center of their own healthcare. Although electronic health records (EHRs) improve the efficiency of an independent physician’s practice, enabling the physician to easily access and input medical data, and providing the patient with electronic  communication tools, the EHR systems of multiple practices must be set up for interoperability to ensure the patient’s records are complete, current, accurate, and that all records are accessible by the patient as well as the independent physician.

Verma stated that the Centers for Medicare & Medicaid Services (CMS) is launching the MyHealthEData Initiative, “a government-wide initiative that will break down the barriers that contribute to preventing patients from being able to access and control their medical records.” Verma further elaborated that “Patients need to be able to control their information and know that it’s secure and private. Having access to their medical information will help them make decisions about their care, and have a better understanding of their health.”

Verma also announced that CMS would “overhaul the documentation requirements of Evaluation and Management codes to make it easier for providers to use their EHRs. These are the codes that doctors use to bill Medicare for patient visits.”

Part of the goal of the new plans outlined at the conference is to help reduce healthcare costs, which are increasing for independent physicians and their patients. Streamlining practice operations and providing higher quality care to patients will contribute to reduced cost and improved, value-based care.

Sam Peirce
April 10, 2018


Bipartisan bill could require every state to use EPCS

In an effort to help combat the opioid addiction crisis and to stem the increase of forged and altered prescriptions, a bipartisan group of US Senators has introduced a bill that would mandate electronic prescriptions be used for controlled substances under Medicare. The Senate group includes Elizabeth Warren, D-Massachusetts; Michael Bennet, D-Colorado; Dean Heller, R-Nevada, and Pat Toomey, R-Pennsylvania.

The “Every Prescription Conveyed Securely Act” was introduced on February 27. The act requires physicians and other health care providers to use electronic prescriptions for controlled substances for Medicare Part D transactions. The mandate would take effect in 2020.

In a letter applauding the Every Prescription Conveyed Securely Act, the National Association of Drug Store Chains pointed out that “EPCS prescriptions cannot be altered, cannot be copied, and are electronically trackable. Furthermore, the federal DEA rules for EPCS establish strict security measures, such as two-factor authentication, that reduce the likelihood of fraudulent prescribing.”

Prescription opioids account for more than half of the opioid-related deaths. Electronic Prescribing for Controlled Substances (EPCS) was introduced as a way to address high rates of drug abuse across the country. By making prescriptions harder to forge or steal, it reduces the ease with which teens and other citizens can access prescription drugs.

The Every Prescription Conveyed Securely Act will “require e-prescribing for coverage under part D of the Medicare program of prescription drugs that are controlled substances.” When discussing the new act, Senator Benet said that “An epidemic of this magnitude requires us to address all aspects of the problem, starting with how providers prescribe opioids. This bipartisan legislation would expand a critical tool to track the use of opioids, ultimately reducing overdoses and saving lives.”

The US Department of Health and Human Services (HHS) reports that, on an average day in the US, more than 650,000 opioid prescriptions are dispensed. Most of those prescriptions are written on paper and handed to the patient, which then makes them susceptible to misuse or fraud. Electronic prescriptions make it much more difficult to forge or steal prescriptions written for controlled substances such as opioids.

Sam Peirce
March 26, 2018


How do new marijuana policies affect independent physicians?

Even though the use of medical marijuana is now allowed in 29 states and the District of Columbia, there is still much uncertainty in regard to legal issues as well as medical protocol surrounding the drug. Marijuana is still illegal on a federal level and the newness of the state laws has left many independent physicians unprepared.

In fact, a study published in Drug and Alcohol Dependence found that nine out of 10 doctors say they are unprepared to prescribe medical marijuana to their patients. More than one-third, just over 35%, of those physicians participating in the survey say they are not prepared to answer patient questions about medical marijuana.

Independent physicians should seek further education about medical marijuana before they can prescribe it appropriately. Unfortunately, clinical studies of the effects of medical marijuana are not conclusive in either its benefits or potential side effects. There are more systematic studies under way, and a January 2017 report from the National Academies of Sciences, Engineering, and Medicine summarized the current evidence on both therapeutic effects and harmful effects while also recommending that further research be carried out.

Exacerbating the problem of a lack of conclusive research is an unwillingness to proactively discuss medical marijuana in medical schools.  The above study found that “only 9% of medical schools have medical marijuana documented in their curriculum and 85% of doctors surveyed said they received no education in medical school or residency on medical marijuana.”

Policy updates related to medical marijuana also are not clear, adding the complexity physicians must manage when considering prescribing this substance.  For example, some state’s policies raise questions about physicians who use telemedicine for their patients who may need medical marijuana. Mary Callison, M.D., who treats medical cannabis patients in Maine and who uses video conferencing, is “fighting new state rules that she says discriminate against disabled, rural and low-income patients.”

Independent physicians who practice in those states in which the use of medical marijuana is allowed will need to be better prepared with an understanding of the benefits and drawbacks of the drug before being able to make an appropriate decision for their patients.

Elation Health will continue to monitor and report on the ongoing debates about the use of medical marijuana and its legality on both a state and federal level.

Sam Peirce
March 23, 2018


Healthcare spending to reach 19.7% of GDP by 2026

Healthcare costs are rising. Medications and services provided by physicians are becoming more expensive. The uncertainty over the status of the Affordable Care Act (ACA) has impacted insurance coverage and premiums. The population of the US is aging and Baby Boomers need more care, even as they transition over to Medicare coverage.

A recent report in Health Affairs states that “under current law, national health spending is projected to grow 5.5 percent annually on average … and to represent 19.7 percent of the economy in 2026.” National healthcare spending is expected to reach the $5.7 trillion mark by 2026. The report points to several “fundamental and demographic factors” driving the increase, including:

  • Trends in disposable personal income
  • Increases in prices for medical goods and services
  • Shifts in enrollment from private health insurance to Medicare that result from the continued aging of the baby-boom generation into eligibility.

Prices for medical goods and services are projected to increase more gradually. The increase in these costs was at historic low rates in the previous three years, have risen only 1.1 percent per year from 2014 to 2016. The projection is for the costs of medical goods and services to increase an average of 2.5 percent per year through 2026.

According to the Health Affairs report, prescription drugs are “projected to experience the fastest average annual spending growth” at 6.3 percent per year through 2026. The projected growth “trend primarily reflects faster-anticipated growth in drug prices, which is attributable to a larger share of drug spending being accounted for by specialty drugs over the coming decade.”

As the population ages, Baby Boomers will become eligible for Medicare as well as Medicaid in growing numbers as their medical needs increase and their income decreases in retirement. Given these factors, the “spending growth in Medicare and Medicaid is a substantial contributor to the faster projected overall growth in national health spending through 2026.”

Sam Peirce
March 20, 2018


Doctors urge HHS to level the playing field for independent practices

Vertical and horizontal integration has impacted the ability of independent physicians to provide quality care to their patients. This was the message sent to the Department of Health and Human Services (HHS), from a group of doctors responding to a Request for Information (RFI) regarding Promoting Healthcare Choice and Competition Across the United States. In part, the RFI’s intent was to seek “input from stakeholders on identifying existing state and federal laws, regulations, guidance, requirements, and other policies that limit choice and competition across health care markets.”

The Physicians Advocacy Institute (PAI) submitted a letter to HHS urging them to consider the independent physician’s contributions as well as their challenges in providing quality healthcare in an age of increased vertical and horizontal integration. Large hospitals and other healthcare facilities are merging, creating even larger and more financially powerful entities. At the same time, many hospitals are acquiring independent physicians’ practices.

The theory behind these integrations and acquisitions is that they lower healthcare costs and improve care coordination. However, PAI questions that theory and instead recommends that HHS “focus on programs and policies that create opportunities for independent physician practices, including solo and small group practices, recognizing the significant contributions these practices make to the nation’s health care.”

The PAI also stated that it “strongly supports HHS’ effort to adopt policies that promote a health care system that provides high-quality care at affordable prices, promotes competition, ensures fair and transparent policies, and prevents excessive consolidation.” Encouraging the HHS to level the playing field for smaller, independent physician practices, the PAI encourages “the Department to take into consideration the differences between practice sizes and the value of each, and to account for those differences as it develops new policies.”

Emphasizing that independent physicians provide quality care to their patients and that the horizontal and vertical integrations quite often impact that level of care, the PAI urged HHS “to have policies that do not limit choice or access, and that support fair practices, bargaining power, and market conditions, so physicians and practices already in the market can continue to provide care to their patients, as well as enabling new entrants and competition into the market.”

Sam Peirce
March 19, 2018


White House holds event to tackle EHR interoperability

Electronic health record (EHR) interoperability was the focus of a White House meeting in December, hosted by Jared Kushner (Senior Advisor to President Donald J. Trump and Director of the White House Office of American Innovation) and Seema Verma (Administrator of the Centers for Medicare & Medicaid Services, CMS). Interoperability is the electronic sharing of patient information between different EHR systems and healthcare providers, improving independent physicians’ ability to effectively coordinate care for their patients.

The meeting on interoperability included several health information technology (IT) experts from across the US, as well as members of the Healthcare Information and Management Systems Society (HIMSS) North America Board of Directors. A group discussion on potential action steps for the government to take regarding EHR interoperability was followed by a number of breakout sessions that addressed more specific topics.

According to the HIMSS, those working session topics included:

  • Government’s role: This session focused on a discussion of possible actions the government can take toward encouraging interoperability as well as a realistic timeframe for achieving interoperability goals.
  • Technical standards and authentication: The question of what would be needed for full industry support was discussed in this session. Questions included how to verify identities for safety and security around protected patient information.
  • Patient and physician engagement: This session focused on solutions to encourage participation among physicians and patients.
  • Public/private partnership: A discussion around how to encourage private sector innovation was the focus of this session, including how the government can jump-start such efforts.

HIMSS states that it “intends to continue to reach out to CMS, the Office of the National Coordinator for Health IT (ONC), and other government agencies, to share its thought leadership on interoperability and emphasize the points in the HIMSS Call to Action: Achieve Nationwide, Ubiquitous, Secure Electronic Exchange of Health Information. The White House has indicated that it also intends to follow up the December meeting with a plan for next steps.

Sam Peirce
March 14, 2018


What is the new budget’s impact on MACRA?

On February 8, President Trump signed into law a bipartisan budget bill that is designed to extend through September 2019. Included in that bill were a number of items directly impacting the medical community, including independent physicians. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was also impacted by the new budget.

Jennifer McLaughlin, senior associate director of government affairs for the Medical Group Management Association (MGMA), in a discussion with Physicians Practice managing editor Gabriel Perna, indicated that she and her association were still “trying to dissect and understand how [the changes] will play out.”

One of the significant aspects of the new budget bill, McLaughlin says, is the repeal of the Independent Payment Advisory Board, or IPAB. This board was an “unelected panel that would not be accountable to voters or stakeholders.” IPAB would have been triggered after Medicare spending exceeded a certain threshold, as part of the Affordable Care Act (ACA).

McLaughlin also noted that the budget bill changes, for the most part, make implementation of MACRA much more sustainable. There are some small changes to the Merit-based Incentive Payment System (MIPS) that have a potentially big impact. Changes to the Cost category will be felt the most by independent physicians.

Within MIPS, the Cost category “continues to be a source of confusion for physician practices … because there hasn’t been a ton of discourse coming from CMS about how it will be measured over time.” Independent physicians and organizations like MGMA did not have the opportunity to work with the Centers for Medicare & Medicaid Services (CMS) before the MIPS program was implemented, to work on the Cost category details.

One of the more positive aspects of the budget bill and its impact on independent physicians and MACRA is a tweak to the language specifying that any MIPS bonuses or penalties will not extend to Part B drugs, McLaughlin noted. Since reimbursement of Part B drugs just a passthrough for physicians, the new verbiage should be beneficial for independent physicians as they calculate costs.

Although McLaughlin states that the new budget bill “gives CMS more time to clarify, test, and develop episode-based cost measures,” independent physician practices are still struggling to determine how the cost category will impact them.

Sam Peirce
March 12, 2018


How the proposed White House budget could affect healthcare

Every year, the White House submits a budget outlining the president’s priorities for the coming year. Although the White House budget generally has no impact on the actual budget passed by Congress, it does give a glimpse into the vision of President Trump in regard to major national undertakings such as military spending, domestic programs, and healthcare.

According to the New York Times, the White House budget “request would add $984 billion to the federal deficit next year, despite proposed cuts to programs like Medicare ….” The Times adds that the proposed budget “contains at least $1.8 trillion in cuts to federal entitlement programs such as Medicaid, Medicare and food stamps.”

An article in VoxCare states that specific changes to Medicare and Medicaid would include:

  • Denying Medicaid benefits to people who cannot prove their immigration status
  • Increasing Medicaid beneficiaries’ copayments for improper use of the emergency room
  • Allowing asset testing, which adds up all the value of a person’s property and belongings, in addition to income as a test of Medicaid eligibility
  • Creating an out-of-pocket maximum for drug expenses for Medicare recipients
  • Allowing more flexibility for Medicare Part D plans to set their formularies, giving them more negotiating leverage.

As to the growing opioid crisis and the ability of the healthcare field to respond appropriately with adequate funding, the White House budget submitted by President Trump “provides $10 billion for vaguely defined efforts to prevent opioid abuse and expand treatment,” according to VoxCare. However, experts say much more is needed, as the opioid crisis currently costs “the entire country $80 billion in a single year.”

The White House budget also proposes eliminating the Agency for Healthcare Research and Quality from the Department of Health and Human Services as well as some healthcare workforce programs designed to train medical students.

Sam Peirce
February 28, 2018