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Washington Update Florida Neurosurgical Society Meeting Katie O. Orrico, Director AANS/CNS Washington Office
Washington Update Florida Neurosurgical Society
Meeting
Katie O. Orrico, Director AANS/CNS Washington Office
Presentation Overview • Health Reform
• Reimbursement
• Communications
• Political Action
Reforming the Reform
• Addressing Omissions: • SGR Fix
• Including private contracting • Medical Liability Reform • Workforce Shortages/GME
• Correcting Commissions: • IPAB Repeal • Quality Penalties • Medical Device Tax Repeal
Moving Forward w/Implementation
7-feet of regulations — over 20,000 pages and growing!
Medicare’s UnSustainable Growth Rate
Congress continues w/short-term “patches” to fix Medicare’s sustainable growth rate (SGR)
• 27% pay cut on Jan. 1, 2014 (w/sequester)
• Cost of Repeal = $139.1 billion ($100 less than previous estimates!)
Top 10 Principles for SGR Reform • Repeal the SGR
• At least 5-year period of payment stability w/annual updates based on MEI
• No pay update differentials between PCPs and specialists
• Choice of voluntary payment models…must maintain a viable fee-for-service option
• Allow private contracting on case-by-case basis
• Positive incentives, rather than penalties, for quality improvement
• Replace current PQRS, EHR, VBPM programs if new quality-based payment system adopted
• Quality measures determined by physicians
• Legal protections for physicians following guidelines and participating in quality programs
• Repeal IPAB
BUT, be careful what we ask for…
SGR Fix
House E&C Bill Phase I:
• Repeals SGR; 5 year payment stability: 2014-18 • Annual update each year = 0.5%
Phase II: • New Quality Update Incentive Program (UIP); Annual
update each year = 0.5% • Quality measure sets & clinical practice improvement
activities for each “peer cohort” (e.g., neurosurgeons); Developed by specialty societies
• Coordinated w/ PQRS (need to clarify qualified clinical data registry program language); Future potential integration w/EHR-meaningful use program
House E&C Bill Phase II (cont’d):
• Quality rating system: scoring scale of 0 to 100; Methodology must be risk-adjusted; Payments based on composite score: − Score of 67 or higher: +1% bonus − Score of 34-66: zero payment adjustment − Score below 34: -1% penalty
• No PQRS penalty if MD participates in UIP; EHR program penalties (-5%), VBPM adjustments (-2%) still apply
• 5% pay cut for MDs who do not participate in UIP
New Payment Model Choice Program: Alternative Payment Models (APMs); MDs can participate in lieu of UIP
House E&C Bill Miscellaneous provisions:
• Development of episodes of care and bundled payments for high volume services
• MDs must report data (volume & time) on the accuracy of RVUs
• In 2016-2018, CMS will identify misvalued services; Medicare spending cut by up to 1% per/yr.
Medical liability protections: Federal healthcare guidelines & quality standards do not establish a standard of care in medical malpractice claim
Evaluation of House E&C Bill Reform Principle Yes No So So
Repeal SGR X 5-year period of payment stability X Payments based on MEI X No pay differentials for specialists & PCPs X Choice of payment models X Viable fee-for-service option X Private contracting X Positive incentives for quality improvement X Replace current PQRS, EHR, VBPM X Quality measures developed by physicians X Legal protections for physicians X IPAB Repeal X
E&C Proposal: Base Payments Fail to Keep Pace w/Inflation
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
Payment Update MEI
Some Concerns w/Alternative Models • ACOs do not easily incorporate surgeons and other
specialists
• Defining episodes of care extremely difficult
• Hospitals and/or PCPs, rather than specialists, will dictate patient care based on payment model, rather than clinical need
• Hospitals and PCPs will dictate how to divide the pie
• Shaving costs may mean eliminating certain implants and other devices from surgeons’ toolbox
• Potential for cherry-picking, limiting access to care for very sick patients
Other Payment Reform Options • House/Senate introduced Medicare Patient
Empowerment Act (MPEA) – H.R. 1310/S. 236 • 16 cosponsors (House); 3 cosponsors (Senate)
• Allows docs and patients to privately contract on case-by-case basis
• No Medicare opt-out
• Hospital other fees still paid www.MyMedicare-MyChoice.org
Sign the
Petition www.MyMedicare-MyChoice.org
Contact Congress
http://capwiz.com/noc/
Next Steps • Congressional Budget Office unveils “score” of
E&C bill
• House Ways and Means and Senate Finance Committees drafting their versions • Revealed in late Sept./early Oct. • Both will incorporate enhanced quality reporting
requirements
Outlook for SGR Repeal Potential Challenges: • Lack of bipartisan consensus on replacement
policy (so far so good) • Price tag for repeal and replace ($140-200b) • Inability to find bipartisan budget offsets • Legislative vehicle uncertain • A lot to do in less than 4 months
Best Guess: Another year-end scramble to pass a short-term “fix”… but we are NOT GIVING UP!
Continuing the Fight for Medical Liability Reform
This is an actual picture from a bench in Pittsburgh, PA
The Trial Bar Never Stops!
Federal Legislation S. 44, Medical Care Access Protection Act • 2 cosponsors • Texas-style stacked cap ($250,000 each provider; max
$500,000 total); expert witness requirements; limits on attorney contingency fees; periodic payment of damages
Rob Portman (R-OH)
Federal Legislation H.R. 36/S. 961, Health Care Safety Net Enhancement Act • 64 cosponsors (House); 1 cosponsor (Senate) • Extends Federal Tort Claims Act liability protections to
physicians serving on-call to the hospital emergency department
Charlie Dent (R-PA)
Roy Blunt (R-MO)
Federal Legislation H.R. 1733, Good Samaritan Health Professionals Act • 15 cosponsors • Limits the liability of physicians who volunteer to
provide health care services in response to a declared natural disaster
Marsha Blackburn (R-TN)
Federal Legislation H.R. 1473, the Standard of Care Protection Act • 11 cosponsors (but included in E&C SGR bill) • Clarifies that lawsuits cannot be based on whether physicians
followed national guidelines or payment policies (e.g., PQRS) created in federal health care laws
Phil Gingrey, MD (R-GA)
Henry Cuellar (D-TX)
Recent State Victories
Florida – SB 1792 • Requires an expert medical witness to be in the same
specialty as the defendant physician
Georgia – Provider Shield Act (HB 499) • Payor guidelines and criteria under federal law (e.g.,
PQRS) shall not establish legal basis for negligence or standard of care for medical malpractice
But… California’s MICRA is AT RISK
IOM Study Overview Institute of Medicine Review will: 1) assess current regulation, financing, content,
governance, and organization of U.S. GME; and 2) recommend how to modify GME to produce a
physician workforce for a 21st century U.S. health care system
Study Timeline: • Start Date: June 2012 • Public meetings held in Sept & Dec • Draft report Summer/Fall 2013 (for peer review) • Final Report Winter 2013-14
Government Accountability Office (GAO) Reports
• Requested by Sens. Tom Coburn (R-OK), Michael Enzi (R-WY) and Richard Burr (R-NC)
• GME Funding Review: • Complete list of federally funded GME and loan
forgiveness programs • Evaluation of return on investment and possible
duplication • Description of all programs available in mid-2013
Government Accountability Office (GAO) Reports
• Workforce Report Objectives: • Recent supply trends, including info on training
and demographics • Projections of future supply and factors affecting
projections • How provisions in ACA may affect future
workforce needs
GME Legislation
Bill Nelson (D-FL)
Charles Schumer (D-NY)
Harry Reid (D-NV)
S. 577: Resident Physician Shortage Reduction Act • 9 cosponsors • Funding for additional 15,000 slots – 3,000 per year
• 1/3 for a “cap-relief pool”; 2/3 for “priority pool” • 50% for primary care; 50% workforce shortage specialties
• Nat’l Health Care Workforce Commission study
GME Legislation H.R. 1180: Resident Physician Shortage Reduction Act • 63 cosponsors • Funding for additional 15,000 slots – 3,000 per year
• 1/3 for a “cap-relief pool”; 2/3 for “priority pool” • 50% for primary care; 50% workforce shortage specialties
• Nat’l Health Care Workforce Commission study
Joseph Crowley (D-NY)
Michael Grimm (R-NY)
GME Legislation H.R. 1201: Training Tomorrow’s Doctors Today Act • 41 cosponsors • Funding for additional 15,000 slots – 3,000 per year
• 1/3 for a “cap-relief pool”; 2/3 for “priority pool” • 50% for primary care; 50% workforce shortage specialties
• 2% IME penalty unless comply w/ ACGME measures • GAO study on shortages; HHS reports on GME funding
Aaron Schock (R-IL)
Allyson Schwartz (D-PA)
GME Legislation H.R. 297, Children’s Hospital GME Support Reauthorization Act • Authorizes $330 m/yr for FY 13-FY 17
(for 55 hospitals) • Passed House of Representatives on
Feb 4, 2013; Pending action in Senate
Yeas Nays NV Republican 171 49 11
Democrat 181 1 18
Total 352 50 29
Independent Payment Advisory Board
• What is the IPAB? • 15 member, government board • Sole purpose: cut Medicare • Limited Congressional oversight • No judicial review • Hospitals exempt from cuts until 2020 • Cuts on top of SGR and other Medicare cuts
IPAB Repeal Physician IPAB Repeal Coalition
• Neurosurgery & Anesthesiology leading effort
• 26 National Specialty Societies, representing 350,000 physicians
• Activities include: • Letters/visits to Congress • Grassroots • Op Eds/Letters to the Editor
• Coordinating with larger IPAB Repeal efforts (PhRMA, HLC, patient groups)
IPAB Repeal Protecting Seniors' Access to Medicare Act
(H.R. 351/S. 351)
Phil Roe, MD (R-TN)
Allyson Schwartz (D-PA)
House Bill 192 cosponsors
170 Rs; 22 Ds
Senate Bill 36 cosponsors
34Rs; 2 Ds
John Cornyn (R-TX)
IPAB Repeal Legislation • Vote in House in Sept (part of ACA repeal efforts)
Litigation • Coons v. Geithner (filed by Goldwater Institute)
• Alleges IPAB violates separation of powers doctrine
Communications • Op Eds & Letters to the Editor
AANS/CNS Letter
Published
The Quality Penalties are Coming! The Quality Penalties are Coming!
2015 BUT CMS started the clock in 2013!
Total 10-yr Payment Adjustment
SGR Deficit
Reduction Sequester
PQRS e-Rx EHR
Value Based
Payment Modifier
2013 -2 -1.5
2014 -24.7 -2 -2
2015 3.6 -2 -1.5 -1 -1
2016 2.6 -2 -2 -2 -2
2017 2.0 -2 -2 -3 ?
2018 1.5 -2 -2 -3 ?
2019 1.0 -2 -2 -4 ?
2020 0.9 -2 -2 -5 ?
2021 1.0 -2 -2 -5 ?
2022 1.3 -2 -2 -5 ?
TOTAL = 80%Cut!
Does not include IPAB and other Medicare Fee Schedule cuts)
Medical Device Tax Repeal • Amendment to Senate Budget: Passed 79 to 20 • Medical Device Access and Innovation Protection Act
(S. 232) • Protect Medical Innovation Act (H.R. 523)
House Bill 260 cosponsors
Senate Bill 35 cosponsors
Orrin Hatch (R-UT)
Amy Klobuchar (D-MN)
Eric Paulsen (R-MN)
Ron Kind (D-WI)
Future Uncertain Given Current State Government!
Other Payment Issues • Third Party Coverage Policies: Rapid Response
Team • BMP • Lumbar & cervical spine fusion • TENS for chronic low back pain • Minimally invasive lumbar interbody fusion • Stereotactic radiosurgery • Surgical and ablative treatments for chronic headaches • Management of carotid atherosclerosis • Mechanical embolectomy
• ICD-10: Implementation Oct. 1, 2014
Political Action • Raised $180,000 in 2013
• $21,175 from Florida NS: THANK YOU!
GOAL: $250,000
• Contributed $188,000 thru 6/30/13
Please contribute!
Democrat Republican Number Amount Number Amount
Individuals 5 $12,000 Individuals 40 $131,000
Political Party 0 $0 Political Party 6 $45,000
TOTAL 5 $12,000 TOTAL 46 $176,000
