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U.S. health care policy: What lies ahead?
The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.
Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.
However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.
As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.
“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”
By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.
The law, however, has not been without its challenges.
“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”
Where we stand January 2017
Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.
“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”
In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.1 The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.2 Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.3 However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”
Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”
Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”
Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.
“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
Key provisions: A delicate balance
Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.
“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”
Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.
As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.
“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.
Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.
“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”
Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.
Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.4
Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.5 Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.
States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.
Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.
And … Medicare
The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.
“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”
Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.1 Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.
“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”
Seniors may also find themselves rationing or skimping on care.
Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.6
MACRA launch
Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.
“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”
Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”
On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.
“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”
Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.
Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.
“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”
At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.
“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”
He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.
2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.
3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.
4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.
5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.
6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.
The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.
Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.
However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.
As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.
“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”
By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.
The law, however, has not been without its challenges.
“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”
Where we stand January 2017
Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.
“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”
In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.1 The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.2 Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.3 However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”
Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”
Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”
Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.
“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
Key provisions: A delicate balance
Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.
“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”
Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.
As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.
“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.
Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.
“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”
Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.
Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.4
Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.5 Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.
States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.
Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.
And … Medicare
The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.
“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”
Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.1 Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.
“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”
Seniors may also find themselves rationing or skimping on care.
Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.6
MACRA launch
Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.
“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”
Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”
On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.
“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”
Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.
Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.
“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”
At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.
“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”
He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.
2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.
3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.
4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.
5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.
6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.
The New Year brings new leadership in the United States, with President-elect Donald Trump taking office later this month. With a Republican-controlled Congress, party leaders have the opportunity to shape the nation’s policies around conservative ideals. This includes health care.
Since the Affordable Care Act (ACA) was passed in 2010, Republicans have vowed to repeal and replace it. This could be their opportunity.
However, “there is no clear coalescence around specific policy reforms that would replace the Affordable Care Act,” says Christine Eibner, PhD, a senior economist at Rand and a professor at the Pardee Rand Graduate School.
As a candidate, Trump did little to advance policy ideas around health care. Meanwhile, House Speaker Paul Ryan (R-Wis.) and others have, over the years, proposed reforms with which Trump may or may not agree.
“The Republicans now have a hard issue in their hands,” says Allison Hoffman, JD, professor of law at UCLA School of Law and an expert on health care law and policy. “It was hard before the Affordable Care Act, and it will be hard after. There is not an easy solution.”
By 2016, the ACA had expanded health coverage to 20 million people through Medicaid and private insurance on health care marketplaces. It extended the solvency of the Medicare Hospital Insurance Trust Fund. It accelerated the pace of delivery system and payment reform through creation of the Center for Medicare & Medicaid Innovation.
The law, however, has not been without its challenges.
“It was a strong achievement to get 20 million people insured, but it’s not clear that it bent the cost curve,” says Dr. Eibner. “There are high premiums on the individual market and still 31 million people without coverage. There is still opportunity to improve.”
Where we stand January 2017
Whether the Republicans can or will repeal the ACA in its entirety and improve it remains unknown. But, the experts say, the landmark law has left its mark on the American health care system.
“Everyone is complaining about the uncertainty created by the election, but we have been dealing with a highly uncertain environment for many years,” says Ron Greeno, MD, FCCP, MHM, senior advisor for medical affairs at TeamHealth, chair of the SHM Public Policy Committee, and SHM president-elect. “There will be changes, but things were going to change no matter the outcome of the election. It continues to require tolerance for change and tolerance for uncertainty.”
In an analysis for the Commonwealth Fund, Dr. Eibner investigated the economic implications of aspects of Trump’s plans as a candidate. Using a computer model that incorporates economic theory and data to simulate the effects of health policy changes, Dr. Eibner found that Trump’s plans (full repeal alone or repeal with tax deductions for health care premiums, Medicaid block grants, or selling health insurance across state lines) would increase the number of uninsured people by 16 million to 25 million, disproportionately impact low-income and sicker patients, expose individual market enrollees to higher out-of-pocket costs, and increase the federal deficit by $0.5 billion to $41 billion.1 The Congressional Budget Office (CBO) estimates full repeal could increase the federal deficit by $137 billion to $353 billion by 2025.2 Rep. Ryan’s plan, A Better Way, proposes providing people more control over their health care, giving tax credits instead of subsidies for premiums, capping the employer-sponsored health insurance tax exclusion, and expanding use of health savings accounts.3 However, Rep. Ryan’s plan “doesn’t reduce the cost of health care. It puts more onus on individuals, and their costs go up,” Ms. Hoffman says. “The weight of that will be more on people who have preexisting conditions.”
Joshua Lenchus, DO, RPh, FACP, SFHM, a member of SHM’s Public Policy Committee and hospitalist at the University of Miami/Jackson Memorial Hospital in Florida, is no fan of entitlement programs like Medicaid but says, “The safety-net hospital where I work would rather have people covered with something than nothing.”
Dr. Lenchus is optimistic that economic reforms under Trump will lead to more jobs, increasing the number of people covered by employer plans. “The economy drives health care reform,” he says. “He has to up his ante now and show people that he can stimulate job growth in this country so we don’t have this middle class that is continuously squeezed.”
Dr. Greeno and Ms. Hoffman, who is also a faculty associate at the UCLA Center for Health Policy Research and vice chair of the Insurance Law Section of the Association of American Law Schools, suggest hospitalists get involved as rules are being shaped and written.
“We want to help reform the delivery system, and we want it to be done right and to be done fairly. We want to have say in how our patients are treated,” Dr. Greeno says.
Key provisions: A delicate balance
Many people equate the ACA with the individual mandate, which requires nearly all Americans to purchase health insurance or pay a fine. The federal government provides subsidies to enrollees between 138% and 400% of the federal poverty level so their out-of-pocket costs never exceed a defined threshold even if premiums go up. These could be on the chopping block.
“The last bill Congress passed to repeal the Affordable Care Act, which Obama vetoed, repealed the individual mandate and subsidies for people to buy insurance,” Ms. Hoffman says. “If they do repeal it, private insurance through the exchanges will crumble.”
Mr. Trump’s tax deductions to offset premium costs are based on income, making them more generous for higher-income earners than low-income ones, Hoffman adds.
As a result, she says, people may choose high-deductible plans and face high out-of-pocket costs if they do seek care.
“It’s asking individuals to save by deciding how they’re going to ration care, where someone says they’re not going to go to the doctor today or fill a prescription drug they need,” Ms. Hoffman says.
Meanwhile, Mr. Trump has said he would like to keep the provision of the ACA that bans insurers from denying individuals with preexisting conditions. This, experts agree, may not be possible if other parts of the law are repealed and not replaced with similar protections for insurers.
“If you try to keep the rules about not including preexisting conditions and get rid of subsidies and the individual mandate, it just won’t work,” Ms. Hoffman says. “You end up with extraordinarily expensive health insurance.”
Rep. Ryan’s plan would prohibit insurers from denying patients with preexisting conditions but only if patients maintain continuous coverage, with a single open-enrollment period. He has promised to provide at least $25 billion in federal funding for state high-risk pools.
Prior to the passage of the ACA, 35 states offered high-risk pools to people excluded from the individual market. The Kaiser Family Foundation shows the net annual losses in these states averaged $5,510 per enrollee in 2011. Premiums ranged from 100% to 200% higher than non–high-risk group coverage. Government subsidies to cover losses amounted to $1 billion in each state.4
Meanwhile, both Mr. Trump and Rep. Ryan have proposed profound changes for Medicaid. Dr. Greeno calls this a “massive political challenge” unless they can provide an alternative way to cover people who currently rely on the federal-state entitlement, as well as those who gained coverage through ACA expansion. Currently, 70 million people are enrolled in Medicaid and the Children’s Health Insurance Program.5 Through Mr. Trump’s suggested block grants, states would receive a fixed amount of money to administer their program with increased flexibility. Rep. Ryan’s plan calls for enrollment caps that would distribute a dollar amount to each participant in the program with no limit on the number of enrollees. Either would be adjusted for inflation.
States could implement work requirements for beneficiaries or ask them to pay a small amount toward their premiums. Expansion states could also lower the Medicaid threshold below 138%.
Some states will struggle to provide for all their enrollees, Ms. Hoffman says, particularly since health spending generally outpaces inflation. Dr. Lenchus is more optimistic. “I believe states that didn’t expand Medicaid, one way or another, will figure out a way to deal with that population,” he says.
And … Medicare
The other entitlement program facing abrupt change is Medicare, typically considered the third rail of American politics.
“This is the hot political moment,” Ms. Hoffman says. “This is the point where the Republicans think they can tick off their wish list. For many Republicans, this kind of entitlement program is the opposite of what they believe in.”
Though Mr. Trump has said before he would not alter Medicare, he remained quiet on this point in the aftermath of the election. Repealing the ACA would affect Medicare by potentially reopening the Part D prescription drug doughnut hole and eliminating some of the savings provisions in the law. In fact, the CBO estimates Medicare’s direct spending would increase $802 billion between 2016 and 2025.1 Rep. Ryan has talked about privatizing Medicare by offering seniors who rely on it vouchers to apply toward private insurance.
“At the highest level, it’s moving Medicare from a defined benefit to a defined contribution program,” Ms. Hoffman says. “It shifts financial risk from the federal government onto beneficiaries. If Medicare spending continues to grow faster than the rest of the economy, Medicare beneficiaries will pay more and more.”
Seniors may also find themselves rationing or skimping on care.
Despite Rep. Ryan’s statements to the contrary, Medicare is not broken because of the ACA, Ms. Hoffman says. Its solvency has been prolonged, and though the reasons are not clear, Medicare spending has slowed since the passage of the ACA.6
MACRA launch
Another key factor in the health care policy landscape is MACRA, the Medicare Access and CHIP Reauthorization Act, which fundamentally shifts the way the government administrates and reimburses physicians for health care. MACRA begins in 2017. Dr. Greeno is concerned that changes to the ACA will impact the testing of payment models CMS is testing.
“There are hundreds of hospitals and thousands of physicians already invested in different models, so I don’t expect anybody has any desire to pull the rug from under physicians who are testing alternative payment models [APMs],” he says. “MACRA was passed on a strong bipartisan vote, and it created an APM track. Obviously, Congress intended APM models to continue to expand.”
Dr. Greeno says hospitalists are helping “shape these models,” working with the CMS and the Physician-Focused Payment Model Technical Advisory Committee (PTAC) “to ensure physicians participate in APMs and feel engaged rather than being a worker in a model someone else controls.”
On the campaign trail, Mr. Trump spoke of importing pharmaceuticals from overseas in an effort to control high prices. This policy is no longer part of his online plan. He also proposes allowing the sale of health insurance across state lines.
“It would be giving enrollees in states with stricter regulations the opportunity to circumvent to a looser state, which undermines the state with the stricter regulations,” Dr. Eibner says. “That would really create winners and losers. People who are healthy can buy a policy in a state with looser regulations, and their costs would likely fall. But someone sicker and older, it would be harder.”
Ms. Hoffman defines such a plan as a “race to the bottom.” Without well-established networks of physicians and hospitals, startup costs in new states are prohibitive, and many insurers may not wish to compete across state lines, she adds.
Repeal of the ACA could also limit some of the health benefits it required of plans on the individual market. For example, policymakers might be allowed to strip the contraceptive coverage regulation, which provides for free birth control.
“The reality is a lot of things changing in health care now were changing before the Affordable Care Act passed – PQRS, value-based purchasing, hospital-acquired infections,” Dr. Greeno says. “MACRA will continue the journey away from fee-for-service toward outcome-based models.”
At such a pivotal time, he strongly encourages hospitalists to join SHM if they are not already members and to get involved in SHM’s Grassroots Network.
“For a society of our age – young – and size, we’ve been tremendously impactful in helping with delivery system reform,” Dr. Greeno says. “I think it’s because we’re supporting change, not trying to stop it. We just want it to be intelligent change.”
He also is “convinced” hospitalists will be “critical to the redesign of the health care system. Since we are going to be taking care of the majority of hospitalized adult patients in hospitals, hospitalists want to have our say.”
Kelly April Tyrrell is a freelance writer in Madison, Wis.
References
1. Eibner C. Donald Trump’s health care reform proposals: Anticipated effects on insurance coverage, out-of-pocket costs, and the federal deficit. The Commonweath Fund website. Available at: http://www.commonwealthfund.org/publications/issue-briefs/2016/sep/trump-presidential-health-care-proposal. Accessed Nov. 17, 2016.
2. Budgetary and economic effects of repealing the Affordable Care Act. Congressional Budget Office website. Available at: https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-Effects_of_ACA_Repeal.pdf. Accessed Nov. 15, 2016.
3. Our vision for a confident America. A Better Way website. Available at: http://abetterway.speaker.gov. Accessed Nov. 17, 2016.
4. Pollitz K. High-risk pools for uninsurable individuals. Kaiser Family Foundation website. Available at: http://kff.org/health-reform/issue-brief/high-risk-pools-for-uninsurable-individuals/. Accessed Nov. 17, 2016.
5. How accessible is individual health insurance for consumers in less-than-ideal health? Kaiser Family Foundation website. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-is-individual-health-insurance-for-consumer-in-less-than-perfect-health-report.pdf. Accessed Nov. 17, 2016.
6. The Affordable Care Act and Medicare. The Commonwealth Fund website. Available at: http://www.commonwealthfund.org/publications/fund-reports/2015/jun/medicare-affordable-care-act Accessed Nov. 17, 2016.
Theranos Receives Biggest Blow as CMS Revokes Certificate for Government Payments
Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.
Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.
Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.
The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.
Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.
The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.
However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.
Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.
"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.
Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.
Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.
The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.
Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.
Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.
Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.
The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.
Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.
The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.
However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.
Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.
"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.
Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.
Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.
The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.
Theranos Inc founder and CEO Elizabeth Holmes, once touted as the Steve Jobs of biotech for her company's innovative blood-testing technology, has been barred by a U.S. regulator from owning or operating a lab for at least two years.
Dealing the biggest blow yet to the privately held company, the Centers for Medicare & Medicaid Services revoked a key certificate for its California lab and terminated the facility's approval to receive government payments.
Medicare is the government's medical insurance program for the elderly, while Medicaid is for the poor.
The sanctions, which also include an unspecified monetary penalty, come six months after the regulator sent a scathing letter to the company, saying its practices were jeopardizing patient health and safety.
Theranos said late on Thursday that it would continue to service its customers through its Arizona lab.
The company, once valued at $9 billion, was founded by Holmes in 2003 to develop an innovative blood testing device that would give quicker results using just one drop of blood.
However, its fortunes waned after the Wall Street Journal published a series of articles starting in October last year that suggested the devices were flawed and inaccurate.
Forbes magazine said last month that the company's value had fallen to about $800 million, while Holmes' own net worth had shrunk to zero from about $4.5 billion - a figure the magazine had said had made her the richest self-made woman in America.
"Everyone wanted her to succeed," Steve Brozak, president of WBB Securities, told Reuters, noting that the basic blood diagnostics sector has not had a significant advance in technology in 90 years.
Walgreens Boots Alliance terminated its relationship with the company last month and closed operations at all 40 Theranos Wellness Centers at its drug stores in Arizona.
Theranos is also facing a class action lawsuit filed in May accusing it of endangering customer health through "massive failures" that misrepresented test results.
The Palo Alto, California-based company is also being investigated by other federal and state agencies, including the U.S. Securities and Exchange Commission and the State Department of Health in Arizona.
Medicare's Managed Care Option Trades Off With Patient Preferences
CHICAGO - Medicare enrollees are moving in greater numbers than ever to the program's managed care option as a way to save money. But the tradeoff is much less ability to use their preferred doctors and hospitals.
Seniors can choose between traditional fee-for-service Medicare - which is accepted by most healthcare providers - or a Medicare Advantage plan. The latter encompasses health maintenance organizations (HMOs) or preferred provider organizations (PPOs), which control costs by creating healthcare provider networks that enrollees must use.
In theory, prospective Advantage enrollees can review lists of in-network providers before opting into a plan. But a new study by the Kaiser Family Foundation (KFF) finds that provider data often is very difficult to review, can be out of date and frequently contain inaccurate information.
KFF's review also found shortcomings in the quality of providers in some Medicare Advantage provider networks. One out of every five plans did not include a regional academic medical center - institutions which usually offer the highest quality care and top specialists. And only 40 percent of Advantage provider networks included top-quality cancer centers, as indicated by membership in the National Cancer Institute's network.
NCI-designated cancer centers offer cutting-edge treatments and tend to have greater access to clinical trials. They are especially important for patients with rare and advanced cancers, or other complicating conditions, said Gretchen Jacobson, KFF's associate director of the program on Medicare policy and co-author of the study.
The upshot: Medicare Advantage may be just fine if you are healthy, but problems may crop up if your healthcare needs become more complex and you have very specific healthcare provider preferences.
This year, 31 percent of Medicare enrollees are in Advantage plans, up from 11 percent in 2010. That number is expected to hit 41 percent by 2026, according to a forecast by the Congressional Budget Office.
When you sign up for Advantage, your Part B premium goes to the insurance company providing the plan. The largest providers are UnitedHealthcare, Humana Inc and Blue Cross Blue Shield.
One often hears critics claim that healthcare providers are bailing out of traditional Medicare in large numbers - but that is not actually the case. Last year, 14 percent of Medicare enrollees who were seeking a new primary care doctor reported major problems in finding a physician who would treat them, according to survey data from the Medicare Payment Advisory Commission, an independent congressional agency. Among those seeking a new specialist, 6 percent reported major problems. In both cases, that represents 1 percent of the total Medicare population.
ADVANTAGES, PITFALLS
Advantage plans often offer extra benefits, such as health club memberships, vision care and some limited dental care. Cost-sharing is often lower, and many plans provide prescription drug coverage with no extra premium. "It can be very attractive to many seniors who are living on a fixed budget," Jacobson said.
The trade-off is limited provider networks - and the challenges prospective enrollees face in determining who they are allowed to see for healthcare, and who is off-limits. KFF reviewed 409 Advantage plans, including 307 HMOs and 102 PPOs. Researchers found provider directories often were riddled with errors, omissions and outdated information.
"There's no reason in this era of technology why this needs to be as difficult as it is," Jacobson said. "People should be able to simply tell the system who their doctors are, the illnesses they have, and get a recommendation for a plan that will work for them."
KFF also found that Advantage provider network quality differs significantly. For example, Los Angeles has three NCI-designated cancer centers. Most of the Advantage plans there do not include any of them, but one plan includes all three.
A report last year by the U.S. Government Accountability Office found that the Centers for Medicare & Medicaid Services (CMS), which runs Medicare, needs to improve its oversight of Advantage plans to assure that provider networks are robust. The report also criticized CMS for doing too little to assess the accuracy of Advantage plan provider lists.
Even when Advantage enrollees are able to confirm participation by their healthcare providers, there is no guarantee that will continue. Advantage plans are free to add or drop health providers during the course of an enrollment season.
That became an especially hot issue in 2014 when UnitedHealthcare dropped providers who covered thousands of the insurer's patients, including the prominent Yale-New Haven Hospital system.
Democrats in Congress have proposed legislation that would prohibit Advantage plans from dropping providers without cause during the middle of an enrollment year.
Under current rules, plans must provide 30 days' notice to enrollees when providers are dropped. Enrollees who lose access to a provider can make a midyear plan change only under very limited circumstances. "You can do it only if you are receiving ongoing care from a provider that is terminated," Jacobson said. "Otherwise you need to wait until the next open enrollment period."
The annual enrollment period for Advantage and Part D prescription drug plans are held from Oct. 15 to Dec. 7 each year. At that point, a beneficiary could switch to a different Advantage plan, or shift back to traditional Medicare. But a serious diagnosis in January would leave you hamstrung until the following year.
Said Jacobson: "It can be a roll of the dice."
(The opinions expressed here are those of the author, a columnist for Reuters.)
CHICAGO - Medicare enrollees are moving in greater numbers than ever to the program's managed care option as a way to save money. But the tradeoff is much less ability to use their preferred doctors and hospitals.
Seniors can choose between traditional fee-for-service Medicare - which is accepted by most healthcare providers - or a Medicare Advantage plan. The latter encompasses health maintenance organizations (HMOs) or preferred provider organizations (PPOs), which control costs by creating healthcare provider networks that enrollees must use.
In theory, prospective Advantage enrollees can review lists of in-network providers before opting into a plan. But a new study by the Kaiser Family Foundation (KFF) finds that provider data often is very difficult to review, can be out of date and frequently contain inaccurate information.
KFF's review also found shortcomings in the quality of providers in some Medicare Advantage provider networks. One out of every five plans did not include a regional academic medical center - institutions which usually offer the highest quality care and top specialists. And only 40 percent of Advantage provider networks included top-quality cancer centers, as indicated by membership in the National Cancer Institute's network.
NCI-designated cancer centers offer cutting-edge treatments and tend to have greater access to clinical trials. They are especially important for patients with rare and advanced cancers, or other complicating conditions, said Gretchen Jacobson, KFF's associate director of the program on Medicare policy and co-author of the study.
The upshot: Medicare Advantage may be just fine if you are healthy, but problems may crop up if your healthcare needs become more complex and you have very specific healthcare provider preferences.
This year, 31 percent of Medicare enrollees are in Advantage plans, up from 11 percent in 2010. That number is expected to hit 41 percent by 2026, according to a forecast by the Congressional Budget Office.
When you sign up for Advantage, your Part B premium goes to the insurance company providing the plan. The largest providers are UnitedHealthcare, Humana Inc and Blue Cross Blue Shield.
One often hears critics claim that healthcare providers are bailing out of traditional Medicare in large numbers - but that is not actually the case. Last year, 14 percent of Medicare enrollees who were seeking a new primary care doctor reported major problems in finding a physician who would treat them, according to survey data from the Medicare Payment Advisory Commission, an independent congressional agency. Among those seeking a new specialist, 6 percent reported major problems. In both cases, that represents 1 percent of the total Medicare population.
ADVANTAGES, PITFALLS
Advantage plans often offer extra benefits, such as health club memberships, vision care and some limited dental care. Cost-sharing is often lower, and many plans provide prescription drug coverage with no extra premium. "It can be very attractive to many seniors who are living on a fixed budget," Jacobson said.
The trade-off is limited provider networks - and the challenges prospective enrollees face in determining who they are allowed to see for healthcare, and who is off-limits. KFF reviewed 409 Advantage plans, including 307 HMOs and 102 PPOs. Researchers found provider directories often were riddled with errors, omissions and outdated information.
"There's no reason in this era of technology why this needs to be as difficult as it is," Jacobson said. "People should be able to simply tell the system who their doctors are, the illnesses they have, and get a recommendation for a plan that will work for them."
KFF also found that Advantage provider network quality differs significantly. For example, Los Angeles has three NCI-designated cancer centers. Most of the Advantage plans there do not include any of them, but one plan includes all three.
A report last year by the U.S. Government Accountability Office found that the Centers for Medicare & Medicaid Services (CMS), which runs Medicare, needs to improve its oversight of Advantage plans to assure that provider networks are robust. The report also criticized CMS for doing too little to assess the accuracy of Advantage plan provider lists.
Even when Advantage enrollees are able to confirm participation by their healthcare providers, there is no guarantee that will continue. Advantage plans are free to add or drop health providers during the course of an enrollment season.
That became an especially hot issue in 2014 when UnitedHealthcare dropped providers who covered thousands of the insurer's patients, including the prominent Yale-New Haven Hospital system.
Democrats in Congress have proposed legislation that would prohibit Advantage plans from dropping providers without cause during the middle of an enrollment year.
Under current rules, plans must provide 30 days' notice to enrollees when providers are dropped. Enrollees who lose access to a provider can make a midyear plan change only under very limited circumstances. "You can do it only if you are receiving ongoing care from a provider that is terminated," Jacobson said. "Otherwise you need to wait until the next open enrollment period."
The annual enrollment period for Advantage and Part D prescription drug plans are held from Oct. 15 to Dec. 7 each year. At that point, a beneficiary could switch to a different Advantage plan, or shift back to traditional Medicare. But a serious diagnosis in January would leave you hamstrung until the following year.
Said Jacobson: "It can be a roll of the dice."
(The opinions expressed here are those of the author, a columnist for Reuters.)
CHICAGO - Medicare enrollees are moving in greater numbers than ever to the program's managed care option as a way to save money. But the tradeoff is much less ability to use their preferred doctors and hospitals.
Seniors can choose between traditional fee-for-service Medicare - which is accepted by most healthcare providers - or a Medicare Advantage plan. The latter encompasses health maintenance organizations (HMOs) or preferred provider organizations (PPOs), which control costs by creating healthcare provider networks that enrollees must use.
In theory, prospective Advantage enrollees can review lists of in-network providers before opting into a plan. But a new study by the Kaiser Family Foundation (KFF) finds that provider data often is very difficult to review, can be out of date and frequently contain inaccurate information.
KFF's review also found shortcomings in the quality of providers in some Medicare Advantage provider networks. One out of every five plans did not include a regional academic medical center - institutions which usually offer the highest quality care and top specialists. And only 40 percent of Advantage provider networks included top-quality cancer centers, as indicated by membership in the National Cancer Institute's network.
NCI-designated cancer centers offer cutting-edge treatments and tend to have greater access to clinical trials. They are especially important for patients with rare and advanced cancers, or other complicating conditions, said Gretchen Jacobson, KFF's associate director of the program on Medicare policy and co-author of the study.
The upshot: Medicare Advantage may be just fine if you are healthy, but problems may crop up if your healthcare needs become more complex and you have very specific healthcare provider preferences.
This year, 31 percent of Medicare enrollees are in Advantage plans, up from 11 percent in 2010. That number is expected to hit 41 percent by 2026, according to a forecast by the Congressional Budget Office.
When you sign up for Advantage, your Part B premium goes to the insurance company providing the plan. The largest providers are UnitedHealthcare, Humana Inc and Blue Cross Blue Shield.
One often hears critics claim that healthcare providers are bailing out of traditional Medicare in large numbers - but that is not actually the case. Last year, 14 percent of Medicare enrollees who were seeking a new primary care doctor reported major problems in finding a physician who would treat them, according to survey data from the Medicare Payment Advisory Commission, an independent congressional agency. Among those seeking a new specialist, 6 percent reported major problems. In both cases, that represents 1 percent of the total Medicare population.
ADVANTAGES, PITFALLS
Advantage plans often offer extra benefits, such as health club memberships, vision care and some limited dental care. Cost-sharing is often lower, and many plans provide prescription drug coverage with no extra premium. "It can be very attractive to many seniors who are living on a fixed budget," Jacobson said.
The trade-off is limited provider networks - and the challenges prospective enrollees face in determining who they are allowed to see for healthcare, and who is off-limits. KFF reviewed 409 Advantage plans, including 307 HMOs and 102 PPOs. Researchers found provider directories often were riddled with errors, omissions and outdated information.
"There's no reason in this era of technology why this needs to be as difficult as it is," Jacobson said. "People should be able to simply tell the system who their doctors are, the illnesses they have, and get a recommendation for a plan that will work for them."
KFF also found that Advantage provider network quality differs significantly. For example, Los Angeles has three NCI-designated cancer centers. Most of the Advantage plans there do not include any of them, but one plan includes all three.
A report last year by the U.S. Government Accountability Office found that the Centers for Medicare & Medicaid Services (CMS), which runs Medicare, needs to improve its oversight of Advantage plans to assure that provider networks are robust. The report also criticized CMS for doing too little to assess the accuracy of Advantage plan provider lists.
Even when Advantage enrollees are able to confirm participation by their healthcare providers, there is no guarantee that will continue. Advantage plans are free to add or drop health providers during the course of an enrollment season.
That became an especially hot issue in 2014 when UnitedHealthcare dropped providers who covered thousands of the insurer's patients, including the prominent Yale-New Haven Hospital system.
Democrats in Congress have proposed legislation that would prohibit Advantage plans from dropping providers without cause during the middle of an enrollment year.
Under current rules, plans must provide 30 days' notice to enrollees when providers are dropped. Enrollees who lose access to a provider can make a midyear plan change only under very limited circumstances. "You can do it only if you are receiving ongoing care from a provider that is terminated," Jacobson said. "Otherwise you need to wait until the next open enrollment period."
The annual enrollment period for Advantage and Part D prescription drug plans are held from Oct. 15 to Dec. 7 each year. At that point, a beneficiary could switch to a different Advantage plan, or shift back to traditional Medicare. But a serious diagnosis in January would leave you hamstrung until the following year.
Said Jacobson: "It can be a roll of the dice."
(The opinions expressed here are those of the author, a columnist for Reuters.)
Medical Marijuana Cuts Medicare Spending and May Reduce Dependency on Prescription Opioids
Physicians wrote significantly fewer prescriptions for painkillers and other medications for elderly and disabled patients who had legal access to medical marijuana, a new study finds.
In fact, Medicare saved more than $165 million in 2013 on prescription drugs in the District of Columbia and 17 states that allowed cannabis to be used as medicine, researchers calculated. If every state in the nation legalized medical marijuana, the study forecast that the federal program would save more than $468 million a year on pharmaceuticals for disabled Americans and those 65 and older.
No health insurance, including Medicare, will reimburse for the cost of marijuana. Although medical cannabis is legal today in 25 states and the District of Columbia, federal law continues to prohibit its prescription in all circumstances.
The new study, published July 6 in Health Affairs, was the first to ask if there's any evidence that medical marijuana is being used as medicine, said senior author W. David Bradford in a phone interview. The answer is yes, said Bradford, a health economist and a professor at the University of Georgia in Athens.
"When states turned on medical marijuana laws, we did see a rather substantial turn away from FDA-approved medicine," he said.
Researchers analyzed Medicare data from 2010 through 2013 for drugs approved by the U.S. Food and Drug Administration (FDA) to treat nine ailments - from pain to depression and nausea - for which marijuana might be an alternative remedy.
They expected to see fewer prescriptions for FDA-approved drugs that might treat the same conditions as cannabis. Indeed, except for glaucoma, doctors wrote fewer prescriptions for all nine ailments after medical marijuana laws took effect, the study found.
The number of Medicare prescriptions significantly dropped for drugs that treat pain, depression, anxiety, nausea, psychoses, seizures and sleep disorders.
For pain, the annual number of daily doses prescribed per physician fell by more than 11 percent.
"The results show that marijuana might be beneficial with diverting people away from opioids," Bradford said.
A 2014 study found that opioid overdose death rates were on average nearly 25 percent lower in states where medical marijuana was legal compared to states where it remained illegal. Chronic or severe pain is considered a primary indicator for medical marijuana in most states where it is legal.
Nearly two million Americans either abused or were dependent on prescription opioids in 2014, according to the U.S. Centers for Disease Control and Prevention (CDC). Since 1999, more than 165,000 Americans have died from prescription opioid overdoses.
Addiction psychiatrist Dr. Kevin Hill questioned whether medical marijuana patients might in some cases be getting inferior or incorrect treatment, and if so, whether the resulting extra healthcare costs would overshadow the Medicare drug savings. Hill, a professor at Harvard Medical School in Boston, was not involved in the new study.
"Fewer opioid prescriptions in medical marijuana states might be a good thing, but I am concerned about the overall quality of care delivered in medical marijuana specialty clinics," he told Reuters Health in an email.
He criticized the implementation of medical marijuana laws in many states as often leading to "medical care that is of poor quality."
Part of the problem stems from a dearth of research into the efficacy of medical marijuana.
Although California became the first state to legalize medical marijuana in 1996, federal law enacted by Congress in 1970 continues to put cannabis in the same category as heroin, Schedule 1 of the Comprehensive Drug Abuse Prevention and Control Act, and finds it has no medicinal value. Consequently, research has been severely limited.
Sheigla Murphy, a medical sociologist who was not involved in the current study, praised it as a major contribution to the literature on the role of medical marijuana in older adults.
Murphy directs the Center for Substance Abuse Studies in San Francisco and has done prior research on marijuana and baby boomers. She said some older adults prefer marijuana to painkillers and sleeping pills.
"It fits with the problems of older age, problems with sleeping, depression, arthritis, worn-out body parts that begin to hurt. Marijuana can relieve these without the side effects of grogginess and worrying about addiction," she said.
"As we're trying to reduce the number of pain medications, I think marijuana would be a welcome addition to the pharmacopeia," she said. "The one thing we know is no one has ever died of it."
SOURCE: http://bit.ly/1lx2GBv
Health Affairs 2016.
Physicians wrote significantly fewer prescriptions for painkillers and other medications for elderly and disabled patients who had legal access to medical marijuana, a new study finds.
In fact, Medicare saved more than $165 million in 2013 on prescription drugs in the District of Columbia and 17 states that allowed cannabis to be used as medicine, researchers calculated. If every state in the nation legalized medical marijuana, the study forecast that the federal program would save more than $468 million a year on pharmaceuticals for disabled Americans and those 65 and older.
No health insurance, including Medicare, will reimburse for the cost of marijuana. Although medical cannabis is legal today in 25 states and the District of Columbia, federal law continues to prohibit its prescription in all circumstances.
The new study, published July 6 in Health Affairs, was the first to ask if there's any evidence that medical marijuana is being used as medicine, said senior author W. David Bradford in a phone interview. The answer is yes, said Bradford, a health economist and a professor at the University of Georgia in Athens.
"When states turned on medical marijuana laws, we did see a rather substantial turn away from FDA-approved medicine," he said.
Researchers analyzed Medicare data from 2010 through 2013 for drugs approved by the U.S. Food and Drug Administration (FDA) to treat nine ailments - from pain to depression and nausea - for which marijuana might be an alternative remedy.
They expected to see fewer prescriptions for FDA-approved drugs that might treat the same conditions as cannabis. Indeed, except for glaucoma, doctors wrote fewer prescriptions for all nine ailments after medical marijuana laws took effect, the study found.
The number of Medicare prescriptions significantly dropped for drugs that treat pain, depression, anxiety, nausea, psychoses, seizures and sleep disorders.
For pain, the annual number of daily doses prescribed per physician fell by more than 11 percent.
"The results show that marijuana might be beneficial with diverting people away from opioids," Bradford said.
A 2014 study found that opioid overdose death rates were on average nearly 25 percent lower in states where medical marijuana was legal compared to states where it remained illegal. Chronic or severe pain is considered a primary indicator for medical marijuana in most states where it is legal.
Nearly two million Americans either abused or were dependent on prescription opioids in 2014, according to the U.S. Centers for Disease Control and Prevention (CDC). Since 1999, more than 165,000 Americans have died from prescription opioid overdoses.
Addiction psychiatrist Dr. Kevin Hill questioned whether medical marijuana patients might in some cases be getting inferior or incorrect treatment, and if so, whether the resulting extra healthcare costs would overshadow the Medicare drug savings. Hill, a professor at Harvard Medical School in Boston, was not involved in the new study.
"Fewer opioid prescriptions in medical marijuana states might be a good thing, but I am concerned about the overall quality of care delivered in medical marijuana specialty clinics," he told Reuters Health in an email.
He criticized the implementation of medical marijuana laws in many states as often leading to "medical care that is of poor quality."
Part of the problem stems from a dearth of research into the efficacy of medical marijuana.
Although California became the first state to legalize medical marijuana in 1996, federal law enacted by Congress in 1970 continues to put cannabis in the same category as heroin, Schedule 1 of the Comprehensive Drug Abuse Prevention and Control Act, and finds it has no medicinal value. Consequently, research has been severely limited.
Sheigla Murphy, a medical sociologist who was not involved in the current study, praised it as a major contribution to the literature on the role of medical marijuana in older adults.
Murphy directs the Center for Substance Abuse Studies in San Francisco and has done prior research on marijuana and baby boomers. She said some older adults prefer marijuana to painkillers and sleeping pills.
"It fits with the problems of older age, problems with sleeping, depression, arthritis, worn-out body parts that begin to hurt. Marijuana can relieve these without the side effects of grogginess and worrying about addiction," she said.
"As we're trying to reduce the number of pain medications, I think marijuana would be a welcome addition to the pharmacopeia," she said. "The one thing we know is no one has ever died of it."
SOURCE: http://bit.ly/1lx2GBv
Health Affairs 2016.
Physicians wrote significantly fewer prescriptions for painkillers and other medications for elderly and disabled patients who had legal access to medical marijuana, a new study finds.
In fact, Medicare saved more than $165 million in 2013 on prescription drugs in the District of Columbia and 17 states that allowed cannabis to be used as medicine, researchers calculated. If every state in the nation legalized medical marijuana, the study forecast that the federal program would save more than $468 million a year on pharmaceuticals for disabled Americans and those 65 and older.
No health insurance, including Medicare, will reimburse for the cost of marijuana. Although medical cannabis is legal today in 25 states and the District of Columbia, federal law continues to prohibit its prescription in all circumstances.
The new study, published July 6 in Health Affairs, was the first to ask if there's any evidence that medical marijuana is being used as medicine, said senior author W. David Bradford in a phone interview. The answer is yes, said Bradford, a health economist and a professor at the University of Georgia in Athens.
"When states turned on medical marijuana laws, we did see a rather substantial turn away from FDA-approved medicine," he said.
Researchers analyzed Medicare data from 2010 through 2013 for drugs approved by the U.S. Food and Drug Administration (FDA) to treat nine ailments - from pain to depression and nausea - for which marijuana might be an alternative remedy.
They expected to see fewer prescriptions for FDA-approved drugs that might treat the same conditions as cannabis. Indeed, except for glaucoma, doctors wrote fewer prescriptions for all nine ailments after medical marijuana laws took effect, the study found.
The number of Medicare prescriptions significantly dropped for drugs that treat pain, depression, anxiety, nausea, psychoses, seizures and sleep disorders.
For pain, the annual number of daily doses prescribed per physician fell by more than 11 percent.
"The results show that marijuana might be beneficial with diverting people away from opioids," Bradford said.
A 2014 study found that opioid overdose death rates were on average nearly 25 percent lower in states where medical marijuana was legal compared to states where it remained illegal. Chronic or severe pain is considered a primary indicator for medical marijuana in most states where it is legal.
Nearly two million Americans either abused or were dependent on prescription opioids in 2014, according to the U.S. Centers for Disease Control and Prevention (CDC). Since 1999, more than 165,000 Americans have died from prescription opioid overdoses.
Addiction psychiatrist Dr. Kevin Hill questioned whether medical marijuana patients might in some cases be getting inferior or incorrect treatment, and if so, whether the resulting extra healthcare costs would overshadow the Medicare drug savings. Hill, a professor at Harvard Medical School in Boston, was not involved in the new study.
"Fewer opioid prescriptions in medical marijuana states might be a good thing, but I am concerned about the overall quality of care delivered in medical marijuana specialty clinics," he told Reuters Health in an email.
He criticized the implementation of medical marijuana laws in many states as often leading to "medical care that is of poor quality."
Part of the problem stems from a dearth of research into the efficacy of medical marijuana.
Although California became the first state to legalize medical marijuana in 1996, federal law enacted by Congress in 1970 continues to put cannabis in the same category as heroin, Schedule 1 of the Comprehensive Drug Abuse Prevention and Control Act, and finds it has no medicinal value. Consequently, research has been severely limited.
Sheigla Murphy, a medical sociologist who was not involved in the current study, praised it as a major contribution to the literature on the role of medical marijuana in older adults.
Murphy directs the Center for Substance Abuse Studies in San Francisco and has done prior research on marijuana and baby boomers. She said some older adults prefer marijuana to painkillers and sleeping pills.
"It fits with the problems of older age, problems with sleeping, depression, arthritis, worn-out body parts that begin to hurt. Marijuana can relieve these without the side effects of grogginess and worrying about addiction," she said.
"As we're trying to reduce the number of pain medications, I think marijuana would be a welcome addition to the pharmacopeia," she said. "The one thing we know is no one has ever died of it."
SOURCE: http://bit.ly/1lx2GBv
Health Affairs 2016.
US Completes "Largest Takedown" of Federal Health Insurance Fraud
WASHINGTON - The U.S. Justice Department said Wednesday that federal law enforcement officials have hit a milestone in 2016 by completing the "largest takedown ever" against defendants allegedly trying to defraud Medicare and other federal insurance programs.
The 2016 takedown involves 301 defendants and a loss amount of $900 million, the department said. That exceeds a record last year, when 243 defendants faced charges in a combined $712 million in losses.
Among the defendants charged in the takedown include two owners of a group of outpatient clinics and a patient recruiter who stand accused of filing $36 million in fraudulent claims for physical therapy and other services that were not medically necessary.
To find patients, the Justice Department alleges the clinic operators and the recruiter targeted poor drug addicts and offered them narcotics so they could bill them for services that were never provided.
Another case that was highlighted on Wednesday involved home health fraud. In that case, a doctor was indicted for billing $38 million for home health services that were not needed or ever provided.
The Justice Department said that about 50 percent of the cases in the 2016 take down involve some form of home health fraud, and about 25 percent involve pharmacy fraud.
WASHINGTON - The U.S. Justice Department said Wednesday that federal law enforcement officials have hit a milestone in 2016 by completing the "largest takedown ever" against defendants allegedly trying to defraud Medicare and other federal insurance programs.
The 2016 takedown involves 301 defendants and a loss amount of $900 million, the department said. That exceeds a record last year, when 243 defendants faced charges in a combined $712 million in losses.
Among the defendants charged in the takedown include two owners of a group of outpatient clinics and a patient recruiter who stand accused of filing $36 million in fraudulent claims for physical therapy and other services that were not medically necessary.
To find patients, the Justice Department alleges the clinic operators and the recruiter targeted poor drug addicts and offered them narcotics so they could bill them for services that were never provided.
Another case that was highlighted on Wednesday involved home health fraud. In that case, a doctor was indicted for billing $38 million for home health services that were not needed or ever provided.
The Justice Department said that about 50 percent of the cases in the 2016 take down involve some form of home health fraud, and about 25 percent involve pharmacy fraud.
WASHINGTON - The U.S. Justice Department said Wednesday that federal law enforcement officials have hit a milestone in 2016 by completing the "largest takedown ever" against defendants allegedly trying to defraud Medicare and other federal insurance programs.
The 2016 takedown involves 301 defendants and a loss amount of $900 million, the department said. That exceeds a record last year, when 243 defendants faced charges in a combined $712 million in losses.
Among the defendants charged in the takedown include two owners of a group of outpatient clinics and a patient recruiter who stand accused of filing $36 million in fraudulent claims for physical therapy and other services that were not medically necessary.
To find patients, the Justice Department alleges the clinic operators and the recruiter targeted poor drug addicts and offered them narcotics so they could bill them for services that were never provided.
Another case that was highlighted on Wednesday involved home health fraud. In that case, a doctor was indicted for billing $38 million for home health services that were not needed or ever provided.
The Justice Department said that about 50 percent of the cases in the 2016 take down involve some form of home health fraud, and about 25 percent involve pharmacy fraud.
MACRA Rule Offers Little Clarity for Hospitalists
Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.
However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.
The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.
For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”
MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.
What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.
To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.
Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).
Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.
However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.
“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”
CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.
The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”
The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.
Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.
“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.
Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.
Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.
“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.
To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH
Corrected version July 13, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.
However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.
The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.
For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”
MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.
What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.
To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.
Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).
Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.
However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.
“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”
CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.
The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”
The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.
Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.
“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.
Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.
Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.
“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.
To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH
Corrected version July 13, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Last year, Congress put an end to the Sustainable Growth Rate (SGR), which had become a yearly battle fought on behalf of and by physicians to prevent significant last-minute cuts to Medicare reimbursement. Many hoped its replacement would provide more stability and certainty.
However, that replacement, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), has been anything but clear. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) issued a Notice of Proposed Rulemaking in what it called a “first step” in implementing MACRA. CMS accepted feedback and input on the proposed rule through June 27, 2016.
The Society of Hospital Medicine worked to provide comment on what it sees as the biggest concerns of hospitalists.
For example, it remains unclear what quality markers CMS will use to evaluate hospitalists under MACRA, says Rush University Medical Center’s Suparna Dutta, MD, MPH, a hospitalist, assistant professor of medicine, and member of the SHM Public Policy Committee (PPC). “The biggest piece is, what will be used universally for all hospitalists and attributed to the work that we do?”
MACRA represents “a milestone” in efforts to “advance a healthcare system that rewards better care, smarter spending, and healthier people,” U.S. Department of Health & Human Services Secretary Sylvia M. Burwell said in a statement issued the day the proposed rule was announced.
What it is designed to do, says Ron Greeno, MD, MHM, president-elect of SHM, PPC chair, and senior advisor for medical affairs at TeamHealth, is push physicians to move toward alternative payment models.
To achieve this, MACRA creates a framework called the Quality Payment Program, which offers physicians two paths for value-over-volume-based payments: MIPS, for Merit-Based Incentive Payment System, and APMs, for Advanced Alternative Payment Models. The benchmark period for both pathways begins Jan. 1, 2017, and MACRA reimbursement would begin Jan. 1, 2019.
Under MIPS, current quality measurement programs are streamlined into a single payment adjustment, including the Physician Value-Based Modifier, the Electronic Health Record (EHR) Incentive Program and the Physician Quality Reporting System (PQRS).
Physicians will not assume risk on the MIPS pathway, but payment adjustments will be based on their MIPS score, which grows each year through 2022 and ranges that year from +9% to -9%. It will be budget neutral: The top half of scorers will see increases in payments, while the bottom half will see cuts. Additional adjustments will be given to top performers through 2024.
However, as Dr. Dutta and fellow PPC member Lauren Doctoroff, MD, FHM, a hospitalist at Beth Israel Deaconess Medical Center and instructor at Harvard Medical School, wrote for The Hospitalist in March 2016, it is not yet clear how MIPS scores will be calculated for hospitalists.
“The problem is that there is not a typical hospitalist in terms of the work that we do,” Dr. Dutta says. “It depends on the hospital and the types of responsibilities the hospitalists have and the types of patients they care for.”
CMS says 50% of the MIPS score will come from six reported measures that reflect different specialties and practices; 25% will come from technology use, with a focus on interoperability and information exchange; 15% will come from clinical improvement practices, like care coordination; and 10% will be based on cost, chosen from among 40 episode-specific measures.
The new hospitalist billing code, which has not yet been implemented, should be a tremendous help under MACRA, Dr. Dutta says. “As CMS plans on using peer-comparison groups for quality and cost measures, it is really important that we now have a specialty billing code for hospitalists, which should ensure we have a fair and valid comparison pool for any metrics we are measured on for MIPS.”
The second path may be much harder for hospitalists to achieve since it requires that physicians share in risk and reward and participate in alternative payment models like Next Generation ACO or the Comprehensive Primary Care Plus model.
Most hospitalists will not be candidates for taking on risks under APM since physicians need to achieve a threshold for taking on more than nominal financial risk, Dr. Dutta says, noting SHM’s efforts to better understand the implications.
“It depends on the the percentage of patients you’re seeing in an APM, and you might hit your threshold if your market has a lot of Medicare ACOs or risk-sharing, but it’s not something hospitalists can consistently plan on,” Dr. Dutta says.
Most hospitalists have little control over whether their facility participates in an APM, Dr. Dutta says, but allowing the APM to which a patient belongs count toward the care provided by hospitalists—though a patient may align with several APMs—may help reach these thresholds.
Feedback from SHM to CMS also included asking to allow the Bundled Payments for Care Improvement Initiative (BPCI) to qualify for APM and seeking clarification into whether hospitalists can tap into cost and quality metrics hospitals are already reporting to CMS.
“Hospitals are collecting a certain amount of data because they have to for Medicare, and that might be a good indicator of what hospitalists are doing,” Dr. Dutta says. This includes services like DVT prophylaxis after surgery in hospitals where hospitalists provide a majority of post-operative care or safety measures like CLABSI (central line–associated bloodstream infection) rates.
To stay up to date with MACRA, visit SHM’s MACRA website and follow @SHMadvocacy on Twitter. TH
Corrected version July 13, 2016.
Kelly April Tyrrell is a freelance writer in Madison, Wis.
Key Medicare Fund Could Exhaust Reserves in 2028: Trustees
WASHINGTON—The U.S. federal program that pays elderly Americans' hospital bills will exhaust reserves in 2028, two years sooner than last year's estimate, trustees of the program said on Wednesday.
In their annual financial review, the trustees also said that the combined Social Security and disability trust fund reserves are estimated to run out in 2034, the same projection as last year.
The Medicare program's trust fund for hospital care is still scheduled to have sufficient funding 11 years longer than the estimate given before the Affordable Care Act was passed, the trustees said.
They put the shortening of the timeline down to changes in estimates of income and cost, particularly in the near term.
A depletion in funds available for Medicare and Social Security does not mean the programs would suddenly stop. At the current rate of payroll tax collections, Medicare would be able to cover 87 percent of costs in 2028. This would fall to 79 percent by 2043 and then gradually increase.
Social Security would be able to pay about three-quarters of scheduled benefits from 2034 to 2090, the trustees said.
WASHINGTON—The U.S. federal program that pays elderly Americans' hospital bills will exhaust reserves in 2028, two years sooner than last year's estimate, trustees of the program said on Wednesday.
In their annual financial review, the trustees also said that the combined Social Security and disability trust fund reserves are estimated to run out in 2034, the same projection as last year.
The Medicare program's trust fund for hospital care is still scheduled to have sufficient funding 11 years longer than the estimate given before the Affordable Care Act was passed, the trustees said.
They put the shortening of the timeline down to changes in estimates of income and cost, particularly in the near term.
A depletion in funds available for Medicare and Social Security does not mean the programs would suddenly stop. At the current rate of payroll tax collections, Medicare would be able to cover 87 percent of costs in 2028. This would fall to 79 percent by 2043 and then gradually increase.
Social Security would be able to pay about three-quarters of scheduled benefits from 2034 to 2090, the trustees said.
WASHINGTON—The U.S. federal program that pays elderly Americans' hospital bills will exhaust reserves in 2028, two years sooner than last year's estimate, trustees of the program said on Wednesday.
In their annual financial review, the trustees also said that the combined Social Security and disability trust fund reserves are estimated to run out in 2034, the same projection as last year.
The Medicare program's trust fund for hospital care is still scheduled to have sufficient funding 11 years longer than the estimate given before the Affordable Care Act was passed, the trustees said.
They put the shortening of the timeline down to changes in estimates of income and cost, particularly in the near term.
A depletion in funds available for Medicare and Social Security does not mean the programs would suddenly stop. At the current rate of payroll tax collections, Medicare would be able to cover 87 percent of costs in 2028. This would fall to 79 percent by 2043 and then gradually increase.
Social Security would be able to pay about three-quarters of scheduled benefits from 2034 to 2090, the trustees said.
Centers for Medicare & Medicaid Services (CMS) Eliminates Two-Midnight Rule's Inpatient Payment Cuts: Report
According to the report, CMS estimated the two-midnight policy would increase Medicare spending by ~$220 million due to expected increases in admissions. Hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates the last three years.
According to the report, CMS estimated the two-midnight policy would increase Medicare spending by ~$220 million due to expected increases in admissions. Hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates the last three years.
According to the report, CMS estimated the two-midnight policy would increase Medicare spending by ~$220 million due to expected increases in admissions. Hospitals also will see a one-time increase of 0.6% in fiscal 2017, making up for the 0.2% reduction to the rates the last three years.
MACRA Provides New Direction for U.S. Healthcare
Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.
This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.
What Is MIPS?
MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.
Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.
The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.
A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.
What Are APMs?
The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.
To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.
Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.
Stick with MIPS? Or Take the Plunge with APM?
How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.
Let’s look at a few scenarios:
Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.
Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.
In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.
Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.
Is MACRA Good for Hospitalists?
Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.
With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.
For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.
With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.
What Issues Should Hospitalists Be Aware Of?
As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.
A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.
In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.
SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.
To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.
Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.
What’s Next?
Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.
SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH
Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.
Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.
This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.
What Is MIPS?
MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.
Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.
The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.
A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.
What Are APMs?
The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.
To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.
Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.
Stick with MIPS? Or Take the Plunge with APM?
How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.
Let’s look at a few scenarios:
Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.
Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.
In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.
Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.
Is MACRA Good for Hospitalists?
Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.
With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.
For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.
With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.
What Issues Should Hospitalists Be Aware Of?
As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.
A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.
In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.
SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.
To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.
Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.
What’s Next?
Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.
SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH
Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.
Last year, Congress passed legislation to permanently eliminate the Sustainable Growth Rate (SGR) formula, created in 1997 and designed to hold Medicare Part B or outpatient spending under control. Allowing the SGR to go into effect would have severely cut physician reimbursements in recent years, but Congress passed legislation each year to temporarily avert these cuts (also known annually as the “doc fix”). In search of a permanent solution, the passage of bipartisan legislation permanently repealing the SGR in 2015 was hailed as a way to ensure more certainty around the future of Medicare payments for physicians.
This legislation (H.R. 2, 114th Congress), sponsored by Rep. Michael C. Burgess (R-Texas) and entitled “Medicare Access and CHIP Reauthorization Act of 2015,” or MACRA, does much more than simply remove the SGR’s threat of broader Medicare payment cuts. The law changes the ways physicians are reimbursed by Medicare and continues to shift our healthcare system away from volume-based reimbursements and toward a value-based payment system.
What Is MIPS?
MACRA creates two value-based payment tracks for physicians. The first, the Merit-Based Incentive Payment System (MIPS), is closer to the old fee-for-service model of reimbursement. However, MIPS takes into account both volume and quality (i.e., payment is adjusted based on physician-quality scores). These physician-specific scores broaden the scope of quality measurement by including new measures related to resource utilization, electronic health record (EHR) use, and clinical improvement practices, along with the traditional clinical quality markers.
Under MIPS, the current Physician Quality Reporting System (PQRS), EHR Incentive Program, and Physician Value-Based Modifier all will be integrated into this single-payment adjustment.
The range of potential payment adjustments based on a physician’s MIPS score grows each year through 2022 (in 2022, adjustments can range from +9% to -9%). The program is budget neutral, which means that increases in payments to high-scoring providers will be offset by decreases in payments to low-scoring providers. For 2019 to 2024, there also will be an additional payment adjustment given to the highest MIPS performers for exceptional performance.
A benefit of MIPS is that it will streamline the various quality-reporting programs currently in place into one single program and does not ask physicians to assume any additional financial risk related to outcomes when taking care of patients. However, the particulars of how the MIPS score will be calculated are yet to be determined, and much of the utility and palatability of this score will depend on the chosen metrics. The goal of these metrics should be that they are meaningful, valid, and attributable to specific providers.
What Are APMs?
The other payment option MACRA provides for physicians allows them to opt out of MIPS and participate in the Alternative Payment Models (APMs) track. To incentivize physicians to take part in this riskier track, providers taking part in APMs will receive some extra money for their participation: a 5% annual lump sum bonus on reimbursement payments. To clarify, qualifying APMs are those where providers take on “more than nominal” financial risk, report on their quality measures, and use certified EHR technology.
To qualify as a participant in an APM (for example, the Medicare Shared Savings Program), providers must hit a threshold for percentage of total revenue received or percentage of patients from qualifying APMs. This threshold will increase over time. For example, from 2019 to 2020, providers must obtain at least 25% of their Medicare revenue or patients via APMs, whereas in 2023, 75% of their Medicare revenue or \ patients will need to come from APMs.
Providers will benefit from the increased reimbursement offered if they participate in APMs. There also is funding allocated in MACRA to help develop quality measures, with a call for physician leads to develop quality standards. This payment model, however, does come with increased financial risk for the provider contingent on patient outcomes. In addition, it may be difficult for all providers to hit the thresholds for participation.
Stick with MIPS? Or Take the Plunge with APM?
How MACRA affects you will depend a lot on the practice environment. As described above, MACRA is designed to move physicians into risk-based payment structures if possible. If possible, or otherwise, to simplify the current fee-for-service mechanism of payment by consolidating various Medicare pay-for-performance programs.
Let’s look at a few scenarios:
Hospitalist A works for a physician group that assumes risk for patients in a MACRA-approved APM and sees only those inpatients as opposed to unassigned patients. Therefore, almost all of hospitalist A’s patients are covered by risk-based contracts, and hospitalist A might be well positioned for the new APM structure.
Hospitalist B works for a group, or a university, and sees whatever patients are admitted to the hospital. Hospitalist B’s eligibility to participate in the APM will depend on the percentage of patients in alternative payment models in their market. If hospitalist B’s market has many Medicare accountable care organizations, and Medicaid and the commercial insurers compensate through a risk-sharing model, hospitalist B might reach the threshold. This is more accidental than planned, however, and hospitalist B might not be able to consistently hit this threshold year after year.
In addition, just working within the model will probably not be enough to qualify. Hospitalist B will need to also take on “more than nominal risk” as a participant in the model. In an employed academic setting, where the hospital is taking on risk as part of an APM, it is unlikely hospitalist B will qualify just by virtue of hospital employment. Hospitalist B must also meet/exceed the patient or payment thresholds under the model.
Bottom line: Given the current situation, we expect many hospitalists will likely be required to participate in MIPS and not qualify for APMs. Understanding the details and expectations now will help them be successful in the future.
Is MACRA Good for Hospitalists?
Most of organized medicine is happy to be free from the annual threat of reimbursement cuts. In addition, the new law might streamline quality reporting. But the specific upside depends on your perspective.
With APMs, a hospitalist might enjoy more upside potential, particularly for high-quality work and EHR use. However, whether it is realistic for most hospitalists to even participate in the model depends on many factors, as described previously, and SHM is advocating for the law to be implemented in ways that will more readily accommodate hospitalist practice and employment structures.
For example, the SHM Public Policy Committee has provided the Centers for Medicare & Medicaid Services (CMS) with realistic options for implementing the APM framework that would allow hospitalist B in the above example to qualify as an APM participant.
With MIPS, the benefit to hospitalists depends a fair amount on the way the law is implemented: how quality reporting happens, what metrics will count as quality improvement efforts, and how utilization of EHRs is measured.
What Issues Should Hospitalists Be Aware Of?
As MACRA is further developed, the main issue for hospitalists will be to ensure fairness in assessing quality and incentive payments. As previously encountered with quality reporting, hospitalists are not differentiated clearly from outpatient providers. As a result, they could suffer from the comparison of their quality outcomes for their sicker hospitalized patients to the patients cared for in a typical primary-care internal medicine practice. This inaccurate comparison poses problems in both models.
A potential solution would be a hospitalist-specific billing code, which would make it easier to identify hospitalists. SHM applied for and advocated for the approval of such a billing code and the request was recently approved by CMS.
In addition, as hospitalists mostly work in groups with shift-based schedules, thus sharing care of patients, individual identifiers may not be as significant as possibly looking at hospital, system, or team-based metrics. Using facility performance measures for both clinical quality and performance improvement—where hospitalists can opt to align with their hospital, which is already reporting quality outcomes—might be one way out of this conundrum. It would take into account the type of facility-level quality improvement work many hospitalists participate in. This also would decrease reporting burden for hospitalist groups.
SHM has advocated for this solution and was able to ensure this concept was included in the law; however, it is unclear when or how CMS will implement it.
To summarize, looking good in quality reporting will continue to be a challenge for hospitalists. It will be critical to keep pressure on CMS to implement solutions that account for the unique situation of our specialty.
Another issue to be aware of is the ability of hospitalists to participate in APMs. As with other facility-based providers, hospitalists have little control over whether their facility participates in an APM. Ways to ensure hospitalists can reach thresholds for participation could include allowing the various APMs that hospitalist patients are aligned with count toward an individual hospitalists’ APM participation total—a solution that SHM is advocating for Medicare to include in the APM framework.
What’s Next?
Much remains to be solidified regarding implementation of MACRA, despite the fact it goes live in a few short years (see Figure 1). CMS has asked for comments and stakeholder input regarding MIPS and APMs, and it will be releasing the first round of rules around MACRA this year.
SHM is actively working with CMS to ensure this legislation will reflect the work we are doing as hospitalists to provide high-quality clinical care for our patients and enhance the performance of our hospitals and health system. TH
Dr. Doctoroff is a hospitalist at Beth Israel Deaconess Medical Center and an instructor of medicine at Harvard Medical School in Boston. Dr. Dutta is a hospitalist at Rush University Medical Center and an assistant professor of medicine at Rush Medical College in Chicago. Both are members of the SHM Public Policy Committee.
CMS Introduces Billing Code for Hospitalists: What You Need to Know
The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.
The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.
Question: What are the benefits to hospitalists using the code?
Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.
There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.
To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.
Q: When will the new code go into effect?
Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.
Q: What happens to hospitalists if they do not use the code?
Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.
I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.
Q: Where can someone go to find the code? Will it be available on the CMS website?
Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.
As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.
Q: What role did SHM play in bringing this code to fruition?
Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.
Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.
This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!
For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.
Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH
Brett Radler is SHM’s communications coordinator.
The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.
The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.
Question: What are the benefits to hospitalists using the code?
Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.
There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.
To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.
Q: When will the new code go into effect?
Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.
Q: What happens to hospitalists if they do not use the code?
Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.
I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.
Q: Where can someone go to find the code? Will it be available on the CMS website?
Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.
As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.
Q: What role did SHM play in bringing this code to fruition?
Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.
Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.
This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!
For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.
Sign up for the network to get the latest news in healthcare policy and discover opportunities to advocate for yourself and fellow hospitalists. TH
Brett Radler is SHM’s communications coordinator.
The Centers for Medicare & Medicaid Services (CMS) recently announced the approval of a dedicated specialty billing code for hospitalists that will soon be ready for official use. This is a monumental step for hospital medicine, which continues to be the fastest growing medical specialty in the U.S., with more than 48,000 practitioners identifying as hospitalists.
The Hospitalist recently discussed the implications of this decision with Ron Greeno, MD, MHM, chief strategy officer for IPC Healthcare and chair of SHM’s Public Policy Committee (PPC), and Josh Boswell, director of government relations at SHM, to answer questions raised by SHM members.
Question: What are the benefits to hospitalists using the code?
Dr. Greeno: As we transition from fee-for-service to quality-based payment models, using this code will become critical to ensure hospitalists are reimbursed and evaluated fairly. Under the current code structure, hospitalists are missing opportunities to be rewarded and may be penalized unnecessarily because they are required to identify with internal medicine, family medicine, or another specialty that most closely resembles their daily practice. What current measures do not account for is that hospitalists’ patients are inherently more complex than those seen by practitioners in these other—most often outpatient—specialties. We as hospitalists face unique challenges and work with patients from all demographics, often with severe illnesses, making it nearly impossible to rely on benchmarks used for these other specialties.
There are a few prime examples of this that illustrate the need for the new code. Under the current system, some quality-based patient satisfaction measures under MACRA, on which hospitalists are being evaluated, pertain to the outpatient setting, including waiting room quality and office staff–irrelevant measurements for hospitalists. Hospitalists are also often incorrectly penalized under meaningful use due to complications brought on by observation status and its classification as an outpatient stay. This can cause both quality and cost measures to be extremely flawed and can misrepresent the performance and cost of hospitalists and hospital medicine groups. In the current billing structure, there is no way to accurately identify hospitalists and enable a definite fix to these problems.
To get what we want (fair measurement using relevant metrics), we must be able to identify as a separate group, and fortunately, now we can. There will be benefits we don’t even know about yet. We have to wait and see how healthcare policy continues to evolve and change moving forward. What we do know is that having this code will help us shape MACRA and future healthcare policy so that it works better for hospitalists as the specialty continues to grow in scope and impact.
Q: When will the new code go into effect?
Boswell: While there is not a set date at this time, CMS has reported that it can take up to a year, mostly due to technical changes that need to be made within their own systems. The code has already been officially approved; we just need to wait a bit longer to actually use it.
Q: What happens to hospitalists if they do not use the code?
Dr. Greeno: Some hospitalists might be nervous about the change after having billed a certain way for so long. While there is no absolute requirement for hospitalists to use the new code, the bottom line is that if hospitalists do not adopt the new code, they risk not receiving fair evaluations. Using this code should provide hospitalists with greater insight into their own performance—the data will be much more accurate and meaningful. This will allow hospitalists to hone in on areas needing improvement and provide them with more confidence that they are being compared using accurate benchmarks.
I want to stress that hospitalists, or in some cases their hospital medicine groups, will need to physically change their specialty affiliation when the code becomes effective. Otherwise, they risk not reaping the benefits associated with the new code and will continue to be evaluated using less-than-optimal benchmarks. The ball is in their court to make the change when the code is available, and SHM will serve as a resource to help ensure they know what to do and when.
Q: Where can someone go to find the code? Will it be available on the CMS website?
Boswell: When the code does become available for use, it will be communicated through various channels at SHM and also through the Medicare Learning Network, the site that houses education, information, and resources for healthcare professionals. It will also likely be distributed through additional Medicare circulars and newsletters.
As more details from CMS become available, we will have more specific information to share with members, including information on our website, webinars with billing and coding experts, email communication, and more. Continue to watch your email and social media channels for the latest updates and information.
Q: What role did SHM play in bringing this code to fruition?
Boswell: We can say with confidence that this effort was driven entirely by SHM. To start, a formal application needs to be filed in order for a code to even be considered. After determining that the benefits associated with this code far outweighed the costs and then receiving the support of our board of directors, SHM’s staff and PPC members collaborated to draft a brief and made the argument for the addition of a hospitalist billing code based on the individual elements CMS requires for consideration.
Due to the fact hospital medicine doesn’t have a board certification, while solid, our argument was far from a slam dunk. After submitting the application, SHM continuously followed up with and pressured CMS through various channels and utilized our grassroots network of hospitalists on the Hill to put this code on legislators’ radars—the result was pressure getting applied from interested members of Congress as well. If it weren’t for the persistent advocacy efforts of SHM and its members over the past several years, this code would not have even been considered, let alone approved.
This is a significant development—to our knowledge, this is the first medical specialty to be granted a code without also having a board certification. We’re thrilled that what we have been advocating for on behalf of our members is now a reality!
For the latest information on the new hospitalist billing code and other important healthcare policy updates, continue to check for SHM emails and follow SHM’s social media channels, including @SHMLive and @SHMAdvocacy on Twitter.
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Brett Radler is SHM’s communications coordinator.