Six months into MACRA rollout, docs are still unprepared

By Virgil Dickson  | June 28, 2017

More than halfway through the first year of the rollout of the Medicare Access and CHIP Reauthorization Act, the majority of medical practice leaders still are not ready to comply with the law, according to a survey by American Medical Association and consulting firm KPMG.

The revelation, outlined in a report released Wednesday, is based on the responses from 1,000 physicians who have been involved in practice decision-making related to MACRA. The survey found that fewer than 1 in 4 physicians interviewed were prepared to meet statutory requirements this year. The revelation could mean that many will face a financial penalty in 2019, which is when 2017 compliance will be measured.

Providers' lack of preparedness for MACRA has been a longstanding concern, but the AMA/KPMG report drilled deeper into the knowledge gaps, according to Larry Kocot, principal at KPMG's Center for Healthcare Regulatory Insight.

The survey found that that 51% of the doctors responding were only somewhat knowledgeable about MACRA and its new quality reporting system, the Merit-based Incentive Payment System, or MIPS.

In addition, 90% felt the reporting requirements were somewhat or very burdensome, given the time it would take to comply with MIPS requirements. The physicians also raised concerns about understanding requirements, how MIPS performance is scored, and the cost required to accurately capture and report performance.

Unsurprisingly, the report found that those without experience with value-based reporting systems were most likely to find MIPS requirements burdensome and feel less prepared for long-term financial success. It also found that respondents in a large practice with 50 or more physicians were more likely to feel prepared.

A CMS spokesman did not respond to a request for comment. However, a week before the AMA/KPMG report was released, the agency announced that more small providers would be exempt from MACRA.

Physician practices with less than $90,000 in Medicare revenue or fewer than 200 unique Medicare patients per year would be exempt under the new draft rule released June 20. The move will exclude about 834,000 more clinicians from complying with the quality reporting program under MACRA. The original threshold was $30,000 or fewer than 100 Medicare patients.

The move was a step in the right direction, according to Kocot.

"Penalizing these providers wouldn't make them learn this any faster," he said.

The vast majority of physicians surveyed, 83%, said they needed more educational opportunities to understand MIPS requirements. Specifically, they wanted to know more about reporting requirements, how compliance with the quality system is scored and potential financial impact of the system.

In conjunction with the findings, the AMA has developed a resources guide to help physicians work toward compliance. Clinicians will be able to view a step-by-step video on minimum reporting requirements to avoid a penalty in 2019 and a payment model evaluator that offers a brief assessment of where a practice stands.

Virgil Dickson reports from Washington on the federal regulatory agencies. His experience before joining Modern Healthcare in 2013 includes serving as the Washington-based correspondent for PRWeek and as an editor/reporter for FDA News. Dickson earned a bachelor's degree from DePaul University in 2007.

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Mental healthcare in the crosshairs of Senate health reform bill

By Steven Ross Johnson  | June 29, 2017

The Senate GOP bill to repeal and replace the Affordable Care Act could reverse progress in expanding access to behavioral health and substance abuse treatment, experts say.

An analysis by the Congressional Budget Office found 22 million Americans would lose coverage under the Better Care Reconciliation Act, mostly through an estimated $772 billion, or 26%, cut to federal Medicaid spending by 2026. The CBO said 15 million fewer people would be on Medicaid by that year.

Mental health advocates fear large cuts to Medicaid because it is the single largest payer for mental health services. On top of that, it would allow states to waive the ACA's requirement that commercial insurers and Medicaid plans cover benefits such as mental health and substance abuse treatment.

Concerns about the bill's impact on treatment for mental illness and addiction have led some GOP senators and governors, including Ohio Sen. Rob Portman and Ohio Gov. John Kasich, to withhold support for the legislation.

"This is going to affect people with mental illness and addiction disproportionately," said Dr. Jeffery Lieberman, chairman of the Psychiatry Department at Columbia University College of Physicians and Surgeons.

But supporters say the bill's Medicaid changes would prompt states to redesign their Medicaid programs to cover their residents more cost-effectively.

The bill would effectively end the ACA's Medicaid expansion to low-income adults by phasing out enhanced federal funding for expansion by 2024. It also would impose a cap on the growth of federal payments to states that experts say likely would force states to cut eligibility, benefits and provider payments.

Medicaid covers more than a quarter of all spending for mental health and substance abuse services. An estimated 30% of adults who have received coverage under the ACA's Medicaid expansion have a serious mental illness and/or substance abuse problems, and about 1.3 million people receive treatment for those disorders through that coverage.

"If the expansion goes away, and if the federal government imposes these draconian cuts, the pressure on clinics will be enormous," said Rebecca Farley David, vice president of policy and advocacy for the National Council for Behavioral Health.

According to David, Medicaid makes up anywhere from 40% to 80% of the payer mix for many of her organization's members. "Without the support of the Medicaid program, many of them cannot keep their doors open."

The uncertainty over the fate of Medicaid has caused anxiety at many behavioral healthcare facilities.

"The consequences of this for many will be life or death," said Ken Taylor, CEO of Valley Cities Behavioral Health Care, a community mental healthcare organization with eight sites in the Seattle area.

Taylor said his clinics have doubled the number of patients receiving care since 2014 to about 12,000 patients, which he said was due to the ACA's Medicaid expansion.

The Senate bill allows states to seek waivers that would grant health insurers the option not to cover benefits such as mental health and substance abuse treatment. Those changes could remove the ACA's limits on patient out-of-pocket costs, which could deter people from seeking needed care.

Behavioral health advocates see some positives in the Senate bill. It would keep in place the requirement for health plans to cover children up to age 26 who are on their family's plan. It also bars insurers from denying coverage for people with pre-existing conditions, including mental illness and substance abuse.

Under the bill, states could extend the number of days their Medicaid program covers psychiatric hospitalizations, up to 30 consecutive days in a month and up to 90 days in a year.

Federal law has long barred Medicaid programs from covering the cost of patients receiving mental health or substance abuse treatment in residential facilities with more than 16 beds. Congress changed the limits on inpatient stays when it included a provision within the 21st Century Cures Act last year allowing Medicaid to cover the costs of up to 15 days.

John Snook, executive director for the Treatment Advocacy Center, said the bill's increase in allowed Medicaid-covered treatment days is significant.

But Snook said the bill overall could deprive people with serious mental illness of access to treatment through its provision to cap Medicaid spending. That could force states to cut eligibility and/or benefits. The CBO said the cap would reduce federal Medicaid spending by 35% in 2036.

Such large cuts would further limit access to care for many, who could end up in facilities that are detrimental to their health and more expensive for taxpayers.

"We know what happens when there isn't enough capacity," Snook said. "People end up in the facilities that will take them, and too often that's a jail."

Steven Ross Johnson has been a staff reporter for Modern Healthcare magazine since 2013 and covers issues involving public health and other healthcare news. Johnson has been a freelance reporter for the Chicago Tribune, Progress Illinois, the Chicago Reporter and the Times of Northwest Indiana and a government affairs reporter for the Courier-News in Elgin, Ill. He received a bachelor's degree in communications from Columbia College in Chicago and a master’s degree in journalism from the Medill School of Journalism at Northwestern University.

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medicaid.gov CIB

Today, the Centers for Medicare & Medicaid Services (CMS) issued an Informational Bulletin (CIB) that describes our intent to use enforcement discretion to focus on working with states to achieve compliance with the managed care regulations when states are unable to implement the July 1, 2017 requirements of the final rule.  To implement this enforcement discretion, states will need to identify for CMS those regulations of the final rule that they are unable to implement by the required compliance date.  This flexibility will not apply to the actuarial soundness, medical loss ratio (MLR), and pass-through payment provisions of the final rule because of the significant federal fiscal implications of these provisions for the Medicaid program.

The informational bulletin can be accessed on Medicaid.gov at http://www.medicaid.gov/Federal-Policy-Guidance/Federal-Policy-Guidance.html.

Health Care Battle On Hill Has Veterans Defending Obamacare Benefits

By Stephanie O'Neill June 30, 2017

Less than half of the 22 million veterans in the U.S. get their health care through the Veterans Affairs system. Many rely on Medicaid, which is slated for reductions under the health plan making its way through the U.S. Senate.

Air Force veteran Billy Ramos, from Simi Valley, Calif., is 53 and gets health insurance for himself and for his family from Medicaid — the government insurance program for low-income people. He says he counts on the coverage, especially because of his physically demanding work as a self-employed contractor in the heating and air conditioning business.

“If I were to get hurt on the job or something, I’d have to run to the doctor’s , and if I don’t have any coverage they’re going to charge me an arm and a leg,” he said. “I’d have to work five times as hard just to make the payment on one bill.”

There are about 22 million veterans in the U.S. But fewer than half get their health care through the Veterans Affairs system; some don’t qualify for various reasons or may live too far from a VA facility to easily get primary health care there. 

Many vets instead rely on Medicaid for their health insurance. Thirty-one states and the District of Columbia chose to expand Medicaid to cover more people — and many of those who gained coverage are veterans.

The GOP health care bill working its way through the Senate would dramatically reduce federal funding for Medicaid, including rolling back the expansion funding entirely between 2021 and 2024.

Medicaid coverage recently has become especially important to Ramos — a routine checkup and blood test this year showed he’s infected with hepatitis C. California was one of the states that chose to expand Medicaid, and the program covers Ramos’ costly treatment to eliminate the virus.

“Right now, I’m just grateful that I do have [coverage],” he said. “If they take it away, I don’t know what I’m going to end up doing.”

The Senate health plan — which proposes deep cuts to federal spending on Medicaid — has veterans and advocates worried. Will Fischer, a Marine who served in Iraq, is with VoteVets.org, a political action group that opposes the Republican health plan.

“If it were to be passed into law, Medicaid would be gutted. And as a result, hundreds of thousands of veterans would lose health insurance,” Fischer said.

It’s too early to know just how many veterans might lose coverage as a result of the Medicaid reductions. First, states would have to make some tough decisions: whether to make up the lost federal funding, to limit benefits or to restrict who would get coverage.

But Dan Caldwell thinks those concerns are overblown. He’s a Marine who served in Iraq and is now policy director for the group Concerned Veterans for America.

“The people who are saying that this is going to harm millions of veterans are not being entirely truthful,” Caldwell said. “They’re leaving out the fact that many of these veterans qualify for VA health care or in some cases already are using VA health care.”

About a half-million veterans today are enrolled in the VA’s health care program as well as in some other source of coverage, such as Medicaid or Medicare. Andrea Callow, with the non-profit group Families USA, wrote a recent report showing that nearly 1 in 10 veterans are enrolled in Medicaid.

“Oftentimes veterans will use their Medicaid coverage to get primary care,” Callow said. “If, for example, they live in an area that doesn’t have a VA facility, they can use their Medicaid coverage to see a doctor in their area.”

Whether a particular veteran qualifies for coverage through the VA depends on a host of variables that she said leaves many with Medicaid as their only option.

But, Caldwell said, rather than fighting to preserve Medicaid access, veterans would be better served by efforts to reform the care the VA provides to those who qualify.

“We believe that giving veterans more health care choice and restructuring the VA so that it can act more like a private health care system will ultimately lead to veterans who use the VA receiving better health care,” he said.

The Urban Institute found that the first two years after the enactment of the Affordable Care Act saw a nearly 44 percent drop in the number of uninsured veterans under age 65 — the total went from 980,000 to 552,000. In large part, that was the result of the law’s expansion of Medicaid.

This story is part of NPR’s reporting partnership with Kaiser Health News.

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CMS Proposes 2018 Policy and Payment Rate Changes for End-Stage Renal Disease Facilities

CMS NEWS FOR IMMEDIATE RELEASE June 29, 2017  Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries CMS Proposes 2018 Policy and Payment Rate Changes for End-Stage Renal Disease Facilities Proposed rule builds patient-centered system of care to increase competition, quality and care  The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would update payment policies for the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS). The ESRD PPS proposed rule is one of several for calendar year 2018 that reflect a broader strategy to relieve regulatory burdens for providers; support the patient-doctor relationship in healthcare; and promote transparency, flexibility, and innovation in the delivery of care. “CMS is committed to transforming healthcare to empower patients and doctors so that they can make the best decisions about their health,” said CMS Administrator Seema Verma. “A focus on patient-centered care allows providers to direct their time and resources to improving health outcomes for all patients rather than complying with burdensome regulations from Washington, D.C.” This proposed rule ensures program stability through payment incentives that focus on improved quality of care at dialysis facilities. The rule covers payment rates for renal dialysis services, including updates to acute kidney injury (AKI), furnished to beneficiaries on or after January 1, 2018. The ESRD Quality Incentive Program (QIP) proposed changes are for payment years 2019, 2020, and 2021, and a number of key dialysis data methodologies and quality measures. The proposed rule also requests comment on how to include individuals with acute kidney injury in the ESRD Quality Improvement Program. These updates will help reduce regulatory burdens and allow providers to improve outcomes based on the unique needs of their patients. In addition to the proposed rule, CMS is releasing a Request for Information to welcome continued feedback on the Medicare program. CMS is committed to maintaining flexibility and efficiency throughout Medicare. Through transparency, flexibility, program simplification, and innovation, we aim to transform the Medicare program and promote the availability of high-value and efficiently-provided care for its beneficiaries. For a fact sheet on the proposed rule, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-06-29.html The ESRD proposed rule (CMS 1674-P) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection/ For more information about the End Stage Renal Disease Program, please visit:  https://www.cms.gov/Center/Special-Topic/End-Stage-Renal-Disease-ESRD-Center.html ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress

Changes to the Payment Error Rate Measurement and Medicaid Eligibility Quality Control Programs

FACT SHEET FOR IMMEDIATE RELEASE June 29, 2017  Contact: CMS Media Relations (202) 690-6145 | CMS Media Inquiries    Changes to the Payment Error Rate Measurement and Medicaid Eligibility Quality Control Programs (CMS-6068-F) Today, June 29, 2017 the Centers for Medicare & Medicaid Services (CMS) posted a final rule that will publish on July 5, 2017 to implement changes to the Payment Error Rate Measurement (PERM) and Medicaid Eligibility Quality Control (MEQC) programs to reflect changes to the way states adjudicate eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) required by law, as well as to implement other changes to the PERM and MEQC programs. SUMMARY The final rule implements policy and operational improvements to the PERM and MEQC programs that will reduce state burden, improve program integrity, and promote state accountability. Changes to the PERM Program The PERM program measures improper payments in the Medicaid program and CHIP. The improper payment rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP. In light of changes to the way states adjudicate eligibility for applicants for Medicaid and CHIP under current law, CMS did not conduct the eligibility measurement component of the PERM program for Fiscal Years (FYs) 2015 through 2018 in order to update the eligibility component measurement methodology and related PERM program regulation. During this time, the 2014 national eligibility improper payment rate was used as a proxy rate, and all states conducted a pilot program with rapid feedback for improvement (known as the Medicaid and CHIP Eligibility Review Pilots) to maintain oversight of state eligibility determinations. CMS made changes to the eligibility measurement component of the PERM program in this final rule, and the eligibility measurement component will resume as of the effective date of the final rule for reporting in 2019. Changes to the PERM program in the final rule include: ·         Review Period: ThePERM program will review Medicaid and CHIP payments made by states July through June of a given year. Under previous regulations, the PERM program reviewed payments made in a Federal FY (October through September). ·         Eligibility Review Responsibility: A federal contractor will conduct PERM eligibility reviews with support from each state. Under previous regulations, states were required to conduct eligibility reviews and report the results to CMS. This will help reduce state burden. ·         Eligibility Universe: The PERM program will conduct eligibility reviews (in addition to medical and data processing reviews) on FFS and managed care payments sampled for the PERM program. The eligibility review will be conducted on the beneficiary associated with the sampled claim. Under previous regulations, states created separate universes of eligible individuals that were sampled for eligibility review. ·         Federal Improper Payments: Improper payments will be cited if the federal share amount is incorrect (even if the total computable amount is correct). Under previous regulations, improper payments were only cited on the total computable amount (i.e., federal share + state share). ·         Sample Sizes: A national sample size will be calculated to meet national Medicaid and CHIP improper payment rate precision requirements. The national sample size will then be distributed across states to maximize precision at the state level, and state-specific sample sizes will be based on factors such as each state’s expenditures and previous improper payment rate. Under the previous rule, state-specific sample sizes were calculated based on the state’s previous improper payment rate and state level precision and combined to total the national sample size. ·         Corrective Action: States will continue to implement Corrective Action Plans (CAPs) for all errors and deficiencies; however, there will be more stringent requirements added for states that have consecutive PERM eligibility improper payment rates over the 3% threshold established under section 1903(u) of the Social Security Act (the Act). ·         Payment Reductions/Disallowances: Potential payment reductions/disallowances under section 1903(u) of the Act will be applicable for eligibility reviews conducted during PERM years in cases where a state’s eligibility improper payment rate exceeds the 3% threshold. CMS will only pursue disallowances if a state does not demonstrate a good faith effort to meet the threshold, which is defined as meeting PERM CAP and MEQC pilot requirements. Changes to the MEQC Program The MEQC program is a separate eligibility review program set forth in section 1903(u) of the Social Security Act (the Act) and requires states to report to the Secretary the ratio of States’ erroneous excess payments for medical assistance under the state plan to total expenditures for medical assistance.  States review Medicaid cases to determine whether the sampled cases meet applicable Medicaid eligibility requirements.  Section 1903(u) of the Act also sets a 3% threshold for eligibility-related improper payments in any fiscal year and generally requires the Secretary to withhold payments to states with respect to the amount of improper payments that exceed the threshold. Similar to the PERM program, states did not operate the MEQC program for FYs 2015 through 2018 so that CMS could update the MEQC methodology and related regulation. Through this final rule, CMS has restructured the MEQC program into a tool that more effectively compliments the PERM program and will help states lower their eligibility improper payment rates. The MEQC program will resume as of the effective date of the final rule.  Changes to the MEQC program include: The MEQC program has been restructured into a pilot program that states conduct during their off-years from the PERM program to ensure continuous oversight of both Medicaid and CHIP state eligibility determinations. States have flexibility to design their MEQC active case pilots to best meet each state’s unique needs. However, should a state have consecutive PERM eligibility improper payment rates over the 3% threshold under section 1903(u) of the Act, CMS will provide direction for active case reviews. States are required to review a number of items not fully reviewed through the PERM program (e.g., negative cases). States must submit corrective actions for identified errors. ### Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter @CMSgovPress

The updated Affordable Care Act Federal upper limits (FUL)

The updated Affordable Care Act Federal upper limits (FUL) calculated in accordance with the Medicaid Covered Outpatient Drug final rule with comment are now available on the Medicaid.gov website at https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Prescription-Drugs/Pharmacy-Pricing.html.  States will have up to 30 days from the July 1, 2017 effective date to implement these updated FULs.  

For further information on the FUL program, please see the Federal Upper Limits page at https://www.medicaid.gov/medicaid-chip-program-information/by-topics/benefits/prescription-drugs/federal-upper-limits.html.