Centers for Medicare and Medicaid Services-CMS

MACRA’S QUALITY PAYMENT PROGRAM HAS GONE LIVE – ACTION REQUIRED IN 2017 TO AVOID PART B PAYMENT REDUCTIONS IN 2019 – QPP BASICS TO KNOW IN GETTING STARTED

A new Congress has convened, a new administration is at the helm, and repeal of the Affordable Care Act (ACA) is on the docket, an action of consequence for, among other things, the Medicare Shared Savings Program (MSSP), primary care medical homes, and other Medicare-developed alternative payment models (APMs). On the other hand, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), establishing a Medicare Part B Quality Payment Program (QPP), is bipartisan legislation of little debate. The American Medical Association, the American Hospital Association, and over 100 other health care entities have appealed to the Administration to preserve value-based care.  https://www.premierinc.com/wp-content/uploads/2017/01/Jan-25-letter1-24-17-Administration.pdf. So, even in the midst of ACA uncertainty, MACRA and its QPP are moving forward. The Centers for Medicare and Medicaid Services (CMS), by rule, has developed a QPP structure that went live on January 1, 2017.

Continue Reading MACRA’s Quality Payment Program Has Gone Live

Update – Insurance Commissioner requests CoOportunity liquidation – district court to decide in late February

Concluding that insufficient funds currently exist to meet its obligations to pay medical claims, Iowa Insurance Commissioner, Nick Gerhart, filed a petition in Polk County District Court on January 29, 2015, concluding that further efforts toward rehabilitation of CoOportunity would be futile and asking for court-ordered liquidation of this non-nonprofit insurer. The Commissioner’s petition cites several factors affecting CoOportunity’s asset position, including congressional action placing an estimated $81 million in risk funding CoOportunity was slated to receive at risk; CMS’s decision in December to not advance additional 2014 funds to CoOportunity; and the unavailability of 2015 federal loan funds until late in 2015. The petition concludes that “further transaction of business by CoOportunity would be financially hazardous to policyholders, creditors, and the public.”

A hearing on liquidation is expected to occur in late February, with court-ordered liquidation expected to take effect as of February 28. Upon liquidation, the Insurance Division will take possession of CoOportunity’s assets and will administer those assets under court supervision. State guaranty funds in Iowa and Nebraska will be utilized to meet payment obligations for claims submitted by CoOportunity insureds up to limits set in law.

Commissioner Gerhart continues to advise Iowans with CoOportunity coverage to find other coverage. “Individuals and employer groups are strongly encouraged to find coverage with another insurance company and then cancel their policy with CoOportunity Health as soon as possible.” The Commissioner particularly advises individuals who purchased CoOportunity coverage through Iowa’s marketplace exchange and who are receiving advance premium tax credits and cost sharing reductions to find alternative coverage through the marketplace exchange by March 1, with open enrollment ending on February 15; while there will be a special enrollment period from March 1-April 29, 2015, to avoid having a gap in financial assistance, those individuals must meet March 1 coverage requirements. Individuals are encouraged to call the marketplace center at 1-800-706-7893 or work with an agent, broker, navigator, or consumer assistance counselor.

The Insurance Division has several informational postings, including CoOportunity alerts for persons insured by CoOportunity and for providers, on its website at www.iid.state.ia.us. The Division also has posted the following frequently asked questions (FAQs) and guidance documents.

  • FAQs for individuals.
  • FAQs for small groups.
  • Guidance on tax credits for certain small employers that cannot offer a qualified health plan (QHP) through the Small Business Health Options Program (SHOP) Exchange because  the employer’s principal business address is in a county in Iowa in which a QHP through the SHOP Exchange is not available for all or part of 2015.
MEDICARE EHR MEANINGFUL USE PENALTY NOTICES ON THEIR WAY TO 257,000

On December 21, the federal Centers for Medicare & Medicaid Services (CMS) began issuing letters to physicians and other health professionals eligible to participate in the Medicare EHR Incentive Program notifying them of a 1% Medicare payment penalty they will incur in 2015 for failing to meet Stage 1 meaningful use (MU) benchmarks for use of electronic health records (EHRs). More than 257,000 eligible professionals (EPs) are slated to receive penalty notification letters, a number the American Medical Association (AMA) says is “worse than we anticipated.” Physicians facing the 1% penalty in 2015 will experience an additional 1% payment reduction in each subsequent year they fail to meet EHR MU objectives, up to a maximum of 5%. A physician who also fails to meet MU e-prescribing objectives set through the Electronic Prescribing Incentive Program will experience an additional 1% penalty reduction in Medicare payment. Of the 257,000 EPs scheduled to be penalized under the EHR meaningful use program in 2015, approximately 28,000 also face the 1% e-prescribing penalty.

Data has not yet been made available to show how many Iowa physicians and other health professionals eligible to participate in these two Medicare incentive programs are facing the 2015 Medicare payment penalties. CMS data does show, however, that from January 2011-October 2014, EPs in Iowa received total incentive payments of $350,896,401 for meeting Stage 1 EHR MU objectives either through Medicare ($244,634,629) or Medicaid ($106,261). National data also indicates that Iowa providers have made substantial progress in implementing and using e-prescribing.

The AMA issued a statement saying that it was “appalled” that more than 50% of all EPs will face MU penalties in 2015. “The penalties physicians are facing under the Meaningful Use program are part of a regulatory tsunami facing physicians,” including potential payment reductions from the Physician Quality Reporting System (PQRS) and the Value-based Modifier Program (VBM) as well as ongoing application of budget sequester cuts. Effective April 1, 2015, physicians also face a 21.2% Medicare payment reduction absent corrective congressional action on the SGR.

Not all physicians are eligible to participate in these Medicare MU incentive programs and many eligible physicians applied for and received hardship exemptions making the 2015 penalties inapplicable to them. Of those who are eligible, many elect not to participate, believing the payment penalties they would incur are far less than the costs, burdens, and problems they would face in purchasing and implementing electronic health record systems at this time. An AMA-RAND study released in October 2013 showed that EHR implementation was a significant factor in growing physician dissatisfaction with medical practice. Physicians say that EHR systems interfere with face-to-face physician-patient interactions; are more cumbersome and expensive to implement than projected; often are not interoperable; and are fraught with operational failings.

The AMA continues to advocate for suspension of EHR MU penalties while promoting EHR MU program improvements to better reflect the current state of EHR system functionality, interoperability, workability, and costs. (Link to October 13, 2014 letter: http://www.ama-assn.org/ama/pub/news/news/2014/2014-10-14-ama-blueprint-improve-meaningful-use.page)

Physicians receiving letters will have until the end of February to challenge CMS’ determination.

CMS announced in November the formation of a new Office of Enterprise Data Analytics (OEDA) and named Niall Brennan as the OEDA’s chief data officer. The OEDA’s overarching goal is to harness CMS’ vast data resources for internal and external use as CMS continues to move away from volume-based to value-based care.

Brennan, who has served in various data analytic roles with CMS, will oversee the OEDA’s collection and dissemination of information in several areas of CMS activity, including the ACA’s marketplace exchanges and Medicare’s Shared Savings and quality incentive programs. CMS’ Principal Deputy Administrator, Andy Slavitt, said this new office “signals to the industry that there is no turning back from the health care data agenda.”