A New President, New Congress, and New Updates to the Medicare Program: What to Expect in 2017

Kate ThomasSenior Director of Advocacy and ReimbursementAmerican Academy of Audiology

Presentation Overview

• Discussion of Political Climate• Current Legislative and Regulatory Issues•What to expect in 2017• Quality Payment Program• New Legislation

Current Political Climate

Where are we now?

Current Political Climate

•20 Days Until November 8th Election•Vote for President•Vote for Congress• In 114th Congress (2015-2017)• Senate: 44 Dems, 54 Reps, 2

Indep.•House: 188 Dems, 246 Reps

Current Political Climate• 115th Congress?• Republicans likely to maintain control of House and Senate

Current Political Climate

• Elections = Opportunities • AAA’s PAC Advisory Board• Identify Important Candidates• Engage Audiologists in Key Districts• Supported Events/Candidates Across the Country:• Senator Patty Murray (D-WA)• Senator Mike Crapo (R-ID)• Senator Johnny Isakson (R-GA)

http://www.audiology.org/advocacy/political-action-committee-pac

Current Political Climate

• Michigan Presence on AAA’s PAC Advisory Board• Emily Nairn, AuD, Chair• Greg Mannarelli, AuD• Heidi Slager, AuD• Sally Tuovila, AuD

• Charge: support policy goals important to audiologists and the practice of audiology through the support of candidates for elective office; Raise and disburse funds• Education and Engagement • Audiologists as Political Players

Political Process/PAC• Raise and contribute money to the campaigns of candidates

supportive of audiology issues.• Support policy goals important to audiologists and the

practice of audiology through the support of candidates for elective office

• Promote better understanding among elected officials of the unique and important role of audiology in the delivery of high quality health care to patients

• Seat at the political “table” • Overseen by the PAC Advisory Board; Includes SAA Liaison

Academy Members: http://www.audiology.org/advocacy/political-action-committee-pac

Political Process/PAC • The Academy cannot directly contribute to political candidates• PAC contributions are different from charitable contributions;

They are NOT tax-deductible • “Restricted class.” This includes non-international members of

the Academy, Academy staff, and the families of both groups. By law, we may not solicit contributions from those outside of the restricted class.

• Every dollar of PAC money goes directly to campaign committees of candidates that the PAC Advisory Board and staff determine to be supportive of audiology issues or prospective supporters. It does not go to postage, operating costs, supplies, etc.

Legislative and Regulatory Issues Impacting Audiologists

Legislative Update

• What are the main legislative issues in the 114th Congress? • Hearing Aid Assistance Tax Credit Act (H.R. 1882): 47

cosponsors; (S. 315): 2 cosponsors• Early Hearing Detection and Intervention Act (H.R. 1344):

28 cosponsors, passed House of Representatives; (S. 2424): 12 cosponsors

• IHS’ Fit to Serve Legislation (H.R. 353, now part of H.R. 3471): 51 cosponsors; (S. 564):9 cosponsors

• Medicare Audiology Services Enhancement Act (H.R. 1116): 38 cosponsors

• Audiology Patient Choice Act (H.R. 2519): 20 cosponsors

Legislative Update

A cosponsor is….

...a senator or representative who adds his or her name as a supporter to the sponsor's bill

Legislative Update

• Hearing Aid Tax Credit Act (H.R. 1882, S. 315)• Introduced in U.S. House of Representatives by Representatives

Devin Nunes (R-CA) and Mike Thompson (D-CA) • Bipartisan Support• 34 Original Cosponsors

• Introduced in U.S. Senate by Senators Dean Heller (R-NV) and Amy Klobuchar (D-MN)

• This legislation provides a tax credit of up to $500 towards the purchase of a hearing aid, or $1,000 if two are needed, available once every five years.

• Academy is an active member of the Hearing Aid Tax Credit Coalition and the Friends of the Congressional Hearing Health Caucus (FCHHC)

Legislative Update

• Early Hearing Detection and Intervention Act of 2015 • Introduced by Representatives Brett Guthrie (R-KY) and Lois Capps

(D-CA) • Reauthorizes federal funding for EHDI programs over the next 5

years• Last reauthorized in 2010 • This legislation makes additional improvements:• Includes young children• Further defines the role of the CDC and HRSA • Improves access to appropriate follow-up care and intervention

services• Passed House (September 2015); Focus on Senate to pass before end

of the year

Legislative Update• Veterans' Access to Hearing Health Act of 2015 (H.R. 353,

now part of H.R. 3471)/Veterans Hearing Aid Access and Assistance Act (S. 564)• IHS “Fit to Serve” Legislation • Introduced by Representatives Sean Duffy (R-WI) and Tim Walz (D-

MN) in House and Senators Jerry Moran (R-KS) and Jon Tester (D-MT) in Senate.

• Grants the Department of Veterans Affairs (VA) the authority to hire hearing aid specialists internally and to determine hearing instrument specialists’ scope of practice within the program.

• Compromise language in House (H.R. 3471); H.R. 3471, the Veteran’s Mobility Safety Act, passes the House on September 12, 2016

• Joint Statement AAA, ASHA, and ADA: http://www.audiology.org/advocacy/audiology-organizations-fight-secure-patient-protections-veterans

Legislative Update

Language in H.R. 3471 reflects compromise:

• (b) REQUIREMENTS.—With respect to appointing hearing aid specialists under sections 7401 and 7402 of title 38, United States Code, as amended by subsection (a), and providing services furnished by such specialists, the Secretary shall ensure that—• a hearing aid specialist may only perform hearing services consistent with the hearing aid

specialist's State license related to the practice of fitting and dispensing hearing aids without excluding other qualified professionals, including audiologists, from rendering services in overlapping practice areas;

• services provided to veterans by hearing aid specialists shall be provided as part of the non-medical treatment plan developed by an audiologist; and

• the medical facilities of the Department of Veterans Affairs provide to veterans access to the full range of professional services provided by an audiologist.

• (c) CONSULTATION.—In determining the qualifications required for hearing aid specialists and in carrying out subsection (b), the Secretary shall consult with veterans service organizations, audiologists,otolaryngologists, hearing aid specialists, and other stakeholder and industry groups as the Secretary determines appropriate.

Legislative Update

• Medicare Audiology Services Enhancement Act (H.R. 1116)• Spearheaded by ASHA and supported by AAO-HNS• Introduced by Representative Gus Bilirakis (R-FL)• Proposes to expand the services for which audiologists

may be reimbursed by Medicare; Does not include cerumen removal or tinnitus• Audiologist must develop a physician approved plan of

care when providing assessment or treatment services• Concerns about physician oversight • The Academy opposes this legislation.

Legislative Update

• Audiology Patient Choice Act (H.R. 2519)• Introduced by Representatives Lynn Jenkins (R-KS) and

Matt Cartwright (D-PA)• This bill would grant audiologists limited license

physician status under the Medicare program, and effectively:• Eliminate the requirement for Medicare patients to

obtain a physician order prior to seeing an audiologist• Allow for comprehensive audiologic benefits under

Medicare• Academy endorsement: Long term goal for the

profession

Joint Advocacy-Audiology Allies

• Patients’ Access to Responsible Care Alliance (PARCA) – a national coalition representing the interests of millions of patients and non-MD/DO health care professionals

• Deaf and Hard of Hearing Alliance (DHHA) - a coalition of consumer and professional organizations focused on federal public policy that can improve the quality of life for people who are deaf or hard of hearing, and all people with hearing loss

• Coalition for Patients’ Rights (CPR) - consists of organizations representing a variety of licensed health care professionals who seek to counter efforts by the AMA Scope of Practice initiative that is designed to limit patients' choice of health practitioners

• Friends of the Congressional Hearing Health Caucus (FCHHC)

• Other Audiology Organizations

Legislative Update

• April 2015: Passage of Medicare Access and CHIP Reauthorization Act of 2015 (H.R. 2)- “MACRA”• Permanent repeal of Sustainable Growth Rate (SGR)-

averts 21.2% reduction to reimbursement• 13 years, 17 temporary “fixes”• Medicare providers receive a 0.5 percent positive

update to Medicare reimbursement for 5 years.• Transition from a fee-for-service to a value system• Beginning 2019, two pathways- MIPS and APMs• MIPS: Quality, Resource Use, Meaningful Use of EHR,

Clinical Practice Improvement Activities- overall composite score

Legislative Update

If a bill doesn’t pass in the 114th Congress, it will be automatically reintroduced in the 115th Congress?

TRUE OR FALSE?

FALSE

Questions?

Legislative and Regulatory Process

• Legislative Process is the “What” • Congress is the only part of government that can create new laws

or change existing laws• Once President signs a bill into law, it is printed in the Statutes at

Large• Ex. Medicare Access and CHIP Reauthorization act (MACRA)

• Regulatory Process is the “How” • Article II of the Constitution says President is responsible for

execution and enforcement of the laws created by Congress • HHS oversees CMS• Rulemaking for MACRA

Regulatory Update • MACRA Passes, Now What? • Rulemaking process begins• CMS solicits comments throughout 2015-2016• MPFS (July 2015)• Request for Information (Nov 2015)• Draft Quality Measure Development Plan (March 2016)• NPRM (June 2016)• Final Rule Released Last Friday (October 14, 2016)

Academy comments available: http://www.audiology.org/practice_management/reimbursement/medicare/medicare-payment-reform-merit-based-incentive-payment

Regulatory Update• MACRA paves the way for the new Quality Payment Program• PQRS sunsets at the end of 2016• Audiologists not eligible for participation until 2019 at the

earliest

Repeal

SGR

Combine existing quality programs

New healthcare delivery models

Regulatory Update

Why? Department of Health and Human Services (HHS) Goals

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Regulatory Update• How? Two ways to take part the new Quality Payment

Program• Merit Based Incentive Payment System (MIPS)• Alternative Payment Models (APMs)

Regulatory Update: Current Quality Reporting

EHR Meaningful

Use

PQRS

VBM

Regulatory Update: MIPS• MIPS• Quality Category

• Replaces PQRS• Clinical Practice Improvement Activities

• New Category• I.e. Patient satisfaction, care coordination, patient and communication

engagement• Advancing Care Information

• Replaces the Medicare EHR Incentive Program also known as Meaningful Use

• Cost/ Resource Use• Replaces the Value-Based Modifier• Calculated in 2017, but will not be used to determine payment

adjustment. In 2018, CMS will use cost category to determine your payment adjustment.

Regulatory Update: MIPS• What do audiologists need to know about CMS’ Quality

Payment Program?• As mentioned, audiologists ineligible for participation until 2019• HOWEVER….

• CMS is focused on successful adoption of these new programs and has encouraged voluntary or “practice” reporting; receive feedback on reporting

• Flexible start anytime between January 1 and October 2, 2017• Audiology Quality Consortium and Audiology Organizations provide

more information to assist members • Monitor QPP implementation and changes

• Where to find information:• Academy Website search key words “MACRA” or “MIPS”• CMS Web Site: https://qpp.cms.gov/

Regulatory Update: MIPS• A total score (0-100) will be given for the 4 components (each

weighted differently) which will be compared to a composite score – Achievement at threshold will receive no payment adjustment – Achievement above threshold will yield a positive payment adjustment– Achievement below threshold will yield a penalty on all claims

• Adjustments may be as high as +/- 4% in 2019, and +/- 9% by 2022

• 2 Year lag– Report in 2017 = payment adjustment in 2019

• Specifics released in final rule• Flexibility in first year known as “transition year”

Regulatory Update: MIPS

Regulatory Update

Question:

How many of you use Electronic Health/Medical Records?

Regulatory Update: APMs• Alternative Payment Models: Different way of providing care

for patients that emphasizes quality and care coordination as opposed to quantity and duplication of services• Categorize healthcare by how providers receive payment

for services• category 1—fee-for-service with no link of payment to

quality• category 2—fee-for-service with a link of payment to

quality• category 3—alternative payment models built on fee-

for-service architecture• category 4—population-based payment

Regulatory Update: APMS• Examples of APMs: Accountable Care Organizations (ACOs)• Network of physicians, healthcare providers, and often, hospitals

who share financial and medical responsibility• The primary care physician (PCP) is typically the coordinator, or

head, of the ACO• ACO providers are incentivized when they save money by avoiding

unnecessary tests and procedures• Skeptics feel patients can be denied access to specialists who are

best-trained to address patient illnesses and conditions that exceed the training of the PCP. Interestingly, Medicare doesn’t pay for preventative services, only illnesses

• In contrast, an ACO typically implements safeguards that lower healthcare costs by minimizing the need for medical care

• Providers paid more for keeping patients healthy and out of the hospital (weight management, tobacco cessation, etc.)

Regulatory Update: APMs • Advanced APMs are a subset of APMs: Practices earn more

for taking on some risk. • Earn a 5% incentive payment by going further in improving

patient care and taking on risk through an Advanced APM • What models are Advanced APMs?• In 2017, we anticipate that these will be Advanced APMs: • Comprehensive ESRD Care (CEC) - Two-Sided Risk • Comprehensive Primary Care Plus (CPC+) • Next Generation ACO Model • Shared Savings Program - Track 2 • Shared Savings Program - Track 3

Regulatory Update: APMs

Question:

How many of you currently participate in APMs or have been approached to participate in an APM?

Coding and Reimbursement Updates for 2017

Coding Updates for 2017• Updates to ICD-10 Codes Take Effect on 10/1/2016• New codes specifically addressing "restricted hearing on the contralateral

side" for conductive, sensorineural, and mixed hearing loss”• H90.A Conductive and sensorineural hearing loss with restricted hearing on the contralateral side

• H90.A1 Conductive hearing loss, unilateral, with restricted hearing on the contralateral side• H90.A11 Conductive hearing loss, unilateral, right ear with restricted hearing on the

contralateral side• H90.A12 Conductive hearing loss, unilateral, left ear with restricted hearing on the

contralateral side• H90.A2 Sensorineural hearing loss, unilateral, with restricted hearing on the contralateral side

• H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side

• H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side

• H90.A3 Mixed conductive and sensorineural hearing loss, unilateral with restricted hearing on the contralateral side• H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted

hearing on the contralateral side• H90.A32 Mixed conductive and sensorineural hearing, unilateral, left ear with restricted

hearing on the contralateral side

Coding Updates for 2017• No New CPT Codes for 2017• Medicare Physician Fee Schedule • Very few changes affecting audiology• Conversion Factor close to 2016 • Final payment rule released early November

• Hospital Outpatient Prospective Payment System• Few changes (92540)• Final rule released early November

• Updates will be provided on the Academy’s Web site: http://www.audiology.org/practice_management/reimbursement/reimbursement

• Coding, reimbursement, or compliance questions? E-mail: reimbursement@audiology.org.

• Role of Coding and Reimbursement Committee

Payment Policy Development• Practice Payment Advisory Council (PPAC)• AMA CPT Editorial Panel• Current Procedural Terminology (CPT): Listing of descriptive terms

and identifying codes for reporting medical procedures services and procedures

• Uniform language that accurately describes medical, surgical, and diagnostic services

• Goal: reliable, nation-wide communication among health care providers (including audiologists), payers, and patients

• AMA owned and copyrighted since 1966• AMA CPT Manual updated annually through the AMA CPT

Editorial Panel• Dr. Brad Stach- Academy CPT Advisor

Payment Policy Development• Relative Value Scale Update Committee (RUC)• Standardized payment based on resource costs• Professional Work• Time to perform service, technical skill, physical and mental

effort, stress/risk to patient• Practice Expense• Cost of space, operations, utilities, equipment, etc.

• Professional Liability Insurance• In 2000, CMS implemented a resource based PLI

• CMS reviews recommendations and makes the final decision regarding values, effective January 1 of the following year. All discussions subject to strict confidentiality

• Influences payment policies for private payers

What’s Next?

State Actions• State Network Subcommittee, divided by region• Monitoring state activities and fostering communication among states• State Leaders Network Regional Survey of Needs• Assess State Priorities• Focus the Activities of the SNS/Academy• Develop Resources

• AudiologyNOW!• State Fair • State focused learning module at AudiologyNOW!

• Panel of members from different states

http://www.audiology.org/about-us/volunteer-opportunities/committees-task-forces/state-network-subcommittee

Looking Ahead…• Significant Changes to Medicare Payments (fluid process)• Emergence of Alternative Payment Models• New Congress/New Legislation/New Administration • National Academy of Sciences, Engineering, and Medicine (formerly, IOM)• Released comprehensive report; “Hearing Health Care for Adults:

Priorities for Improving Access and Affordability”• http://www.audiology.org/news/nas-report-hearing-care-adults

• FDA• Re-opened consideration of Draft Guidance Regarding Regulation of

Personal Sound Amplification Products (PSAPs)• Considers OTC hearing aids and elimination of medical evaluation

requirement• http://

www.audiology.org/advocacy/federal/regulatory-issues/fda-regulation-hearing-aid-devices-and-personal-sound

Advocacy at the Academy • Who are we? • Staff• Committees/Committee Volunteers

• Government Relations Committee (GRC)• PAC Advisory Board• State Network Subcommittee (SNS)• Practice Compliance Committee (PCC)• Coding and Reimbursement Committee (CRC)• Practice Payment Advisory Council (PPAC)

• Consultants• ADVI• Korris Group

• Leadership• YOU!

Academy Resources • Legislative Action Center: http://capwiz.com/audiology/home/• PAC:

http://www.audiology.org/advocacy/political-action-committee-pac

• GR News: http://www.audiology.org/advocacy/government-relations-news

• Public Policy Resolutions: http://www.audiology.org/advocacy/public-policy-resolutions-0

• MACRA/MIPS: http://www.audiology.org/practice_management/reimbursement/medicare/medicare-payment-reform-merit-based-incentive-payment

• Publications: Weekly AT E-Newsletter; Column in AT• Staff

Contact

• Kate Thomas, senior director of advocacy and reimbursement kthomas@audiology.org

703-226-1029

• For Coding and Reimbursement Questions, e-mail reimbursement@audiology.org