CMS PROPOSED RULE WOULD INCREASE PAYMENT TO FAMILY PHYSICIANS BY 7 PERCENT

FOR IMMEDIATE RELEASE                                Contact: CMS Media Relations Group

July 6, 2012                                                                                     (202) 690-6145

The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would increase payments to family physicians by approximately 7 percent and other practitioners providing primary care services between 3 and 5 percent.  The increase in payment to family practitioners is part of the proposed rule that would update payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013.  Under the MPFS, Medicare pays more than 1 million physicians and nonphysician practitioners that provide vital health services to Medicare beneficiaries. 

“Helping primary care doctors will help improve patient care and lower health care costs long term,” said CMS Acting Administrator, Marilyn B. Tavenner. 

The 7 percent increase for family physicians comes from a proposal that continues the Administration’s policies to promote high quality, patient-centered care.  For CY 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.  The proposed rule also asks for public comment on how Medicare can better recognize the range of services community physicians and practitioners provide as part of treating patients either through face-to-face services in the office or coordinating care outside the office when the patient does not see the physician.

As has been the case every year since CY 2002, CMS projects a significant reduction in MPFS payment rates under the Sustainable Growth Rate (SGR) methodology due to the expiration of the adjustment made for CY 2012 in the statute.  For CY 2013, CMS projects a reduction of 27 percent and is required by law to include this reduction in these calculations. However, Congress has acted to avert the cuts every year since 2003.  The Administration is committed to fixing the SGR formula in a fiscally responsible way.

The proposed rule would also continue the careful implementation of the physician value-based payment modifier (Value Modifier) that was included in the Affordable Care Act by providing choices to physicians regarding how to participate.  The Value Modifier adjusts payments to individual physicians or groups of physicians based on the quality of care furnished to Medicare beneficiaries compared to costs.  The law allows CMS to phase in the Value Modifier over three years from CY 2015 to CY 2017.  For the CY 2015 physician payment rates, the proposed rule would apply the Value Modifier to all groups of physician with 25 or more eligible professionals.  The proposed rule also provides an option for these groups to choose how the Value Modifier would be calculated based on whether they participate in the Physician Quality Reporting System (PQRS).  For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set their Value Modifier at a 1.0 percent payment reduction.  For groups that wish to have their payment adjusted according to their performance on the value modifier, the rule proposes a system whereby groups with higher quality and lower costs would be paid more, and groups with lower quality and higher costs would be paid less. The performance period for the CY 2015 Value Modifier was established as CY 2013 in the MPFS Final Rule for CY 2012. 

The proposed rule continues efforts by CMS to align quality reporting across programs to reduce burden and complexity. The proposed rule proposes changes to two quality reporting programs that are associated with the MPFS – the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology.  The PQRS proposal includes simplified, lower burden options for reporting and the proposed rule aligns quality reporting across the various programs in support of the National Quality Strategy.  The proposed rule also addresses the next phase in a plan to enhance the Physician Compare Website to foster transparency and public reporting of certain information to give beneficiaries more information for purposes of choosing a physician.

The proposed rule also includes:

• A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system;
• A proposal to implement a durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items;
• A proposal to apply a multiple procedure payment reduction (MPPR) policy to the technical component of the second and subsequent cardiovascular and ophthalmology diagnostic services furnished by the same doctor to the same patient on the same day;
• A proposal to collect data on patient function to improve how Medicare pays for physical and occupational therapy, and speech language pathology services;
• A request for public comments on payment for advanced diagnostic molecular pathology services;
• A proposal to revise a regulation that only allows Medicare to pay for portable x-rays ordered by an MD or DO.  The revised regulations would allow Medicare to pay for portable x-ray services ordered physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law;
• A proposal to clarify when Medicare will pay for interventional pain management services provided by Certified Registered Nurse Anesthetists (CRNAs) when permitted by State law.  This proposal will foster access to pain management services in areas where states have determined that CRNAs may provide these services.

The proposed rule will appear in the July 30, 2012 Federal Register.  CMS will accept comments on the proposed rule until Sep. 04, 2012, and will respond to them in a final rule with comment period to be issued by Nov. 1, 2012.
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Today's Datapoint

20% ... of physicians are in discussions to join or form ACOs, according to the 2012 National Physician Survey conducted by the little blue book and Sharecare.

Quote of the Day

The Supreme Court’s ruling that it was improperly coercive for the federal government to force states to expand Medicaid rolls or have federal funds withheld “truly breaks new ground. It’s the first time since the 1930s that the Supreme Court has invalidated a federal spending statute that gives money to states and attaches strings. A number of other federal spending programs that attach strings will now be attacked as coercive.”

— Harvard law professor Richard Fallon told The Washington Post.

2013 CMS Marketing Guidance Changes Disclaimers, Website Review, Star Ratings

Reprinted from MEDICARE ADVANTAGE NEWS, biweekly news and business strategies about Medicare Advantage plans, product design, marketing, enrollment, market expansions, CMS audits, and countless federal initiatives in MA and Medicaid managed care.

By James Gutman, Managing Editor

June 21, 2012 Volume 18 Issue 12

Perhaps the best news for Medicare Advantage plans in the final CMS 2013 marketing guidance released June 6 is that the size of the guidance document is 120 pages versus 192 for the 2012 guidance. As the shrinkage may suggest, there are not a lot of new requirements for MA sponsors for the coming marketing season. But there are some changes, including in important areas such as disclaimers, time frames for actions to occur, and website reviews, along with a general toughening of rules regarding marketing on CMS’s star quality ratings.

The “biggest caution” consulting firm Gorman Health Group, LLC has regarding the guidelines, President Jeff Fox tells MAN, is that just because the number of pages shrunk substantially, this does not necessarily mean CMS eliminated requirements. In some cases, Fox notes, CMS instead only eliminated repetition or placed the requirements in other manual chapters or guidance documents instead of this new Chapter 3 in the Medicare Managed Care Manual.

Looking at the 2013 guidance overall, he says one significant change is in the area of disclaimers, such as when material is considered for purposes of enrollment versus just for information. Fox warns that disclaimers constitute the No. 1 reason MA marketing materials are declined by CMS. “Make sure you have the required language,” he says.

Another significant new requirement, according to Fox, is that for 2013 two of the three required outbound enrollment and verification (OEV) calls within 15 days of receipt of the application must be made within the first 10 days. These calls are done on enrollments obtained by both independent and employed agents/brokers to ensure that new members understand the plan’s rules. Fox points out that “the clock starts” the day the beneficiary and agent sign the enrollment, so if agents are very busy and don’t send in the enrollments right away, this can be a problem.

Also newly required is that the Multi-Language Insert containing information translated into several languages and offering free interpreter services for answering questions about plans must be sent with all Summary of Benefits and Annual Notice of Changes (ANOC) documents to members. Plans may incorporate this into those materials or have it as a separate document, but it no longer is required only when at least 5% of the sponsor’s plan benefit package service area has a given foreign language as its primary language. “Everybody has to have it,” Fox emphasizes.

Some of the changes are positive for plans, he notes. Under the 2013 guidelines, for example, says Fox, not all call-center scripts need to be filed with CMS. If the material involved is just informational, he explains, plans just need to maintain it and to produce it if asked during plan audits, but it doesn’t need to be transmitted on an ordinary basis.

Among the areas that have new regulations are ones that are relatively new and hot — including plan websites and the marketing of a plan’s star ratings. The section on websites, for example, Fox says, features a fundamental change. In the past, he recalls, if a plan filed required information for the website and CMS performed a random audit and found a problem, the plan could keep the section with the problem posted and, until the problem is resolved, just add a disclaimer that it is being fixed. Now CMS is saying that if there is an error, the plan must take down the entire section with the error until it is fixed, he says, adding, “This is kind of big.”

So too are some of the changes CMS is making on star-ratings marketing. The agency clearly is concerned about plans that trumpet their high ratings in a particular category of the star ratings and might leave the impression that this score is their overall star rating. So it is setting firm guidelines on how the ratings may and may not be used for marketing purposes.

Overall Star Ratings Must Be Included

“Plan sponsors may only reference the contract’s individual measures in conjunction with its overall performance rating in marketing materials,” the guidance states. “Plan sponsors may not use their star rating in a lower category or measure to imply a higher overall plan rating in their marketing materials than is actually the case.” Citing the example of a plan getting the top score of 5 in customer service promoting itself as a five-star plan when its overall plan rating is only two stars, CMS says, “Sponsors must use their star ratings in marketing materials in a manner that does not mislead beneficiaries into enrolling in plans based on inaccurate information.”

Even five-star plans, which now are allowed to market year-round and to use CMS’s gold-star icon on their marketing materials, are not immune from new requirements regarding that. CMS says, “The icon must be included in a way that is not misleading and makes it clear to the audience that the 5-star rating is for a specific contract(s), as applicable. Parent organizations with only one 5-star contract should not create materials in a way that implies all of its contracts achieved this rating.”

CMS is concerned that star ratings might be misconstrued by consumers, says Mary Kaye Thibert, a vice president at Gorman Health Group. While Thibert tells MAN she didn’t see plans seek to market individual star ratings rather than their overall ratings in the West, where she is based, she would have recommended that MA plans market both a specific major rating and the overall rating in situations where both are strong.

She acknowledges, though, that many Medicare beneficiaries still don’t understand the star ratings. If CMS educates consumers more about the ratings, this could change, she adds.

The most significant star-rating-related marketing guidelines change for 2013, according to Thibert, is a requirement that plans doing stars marketing update the ratings in their promotional materials within 15 days of receipt of the final 2013 ratings, instead of 30 days as previously.

The difficulty on this stems from the calendar: The final ratings last year were released Oct. 12, and product-specific marketing began Oct. 1. The problem, Thibert explains, is that many big plans have the star ratings included in large amounts of pre-collated marketing materials and now would have to rapidly change and replace the affected pages.

Linda Armstrong, executive vice president and health insurance practice leader at direct-marketing specialist DMW Worldwide, says this change in the guidance is manageable. It means DMW will recommend to its MA plan clients that they put anything related to their star ratings in either “buckslips” or personalized copy that can be changed quickly and inexpensively, she says.

A more significant issue for DMW in the guidelines, Armstrong tells MAN, is that television advertising “now appears to be a 45-day [review by CMS] submission.” She bases this conclusion on the lack of a reference as in the previous-year guidelines to TV ads as falling in the “file and use” submission category. By contrast, in the guidelines for 2012, CMS specifically said, “Television advertisements are File & Use documents.”

Because of that previous assurance, adds Armstrong, “we could concentrate on getting direct mail submitted and then work on TV later. Now, this will need to be a part of the 45-day crunch of submissions.”

View the final marketing guidelines at www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPartCMarketi...

States Could Cut Medicaid Rolls In 2014 As A Result Of Court Ruling

By Phil Galewitz

KHN Staff Writer

Jul 03, 2012

Starting in 2014, things could get worse for people in Medicaid.

Not only could some states opt out of increasing the number of adults in the government health insurance program for the poor as a result of the Supreme Court’s ruling, but they also could cut people now enrolled.

This wasn’t supposed to happen under President Barack Obama’s health law designed to expand coverage for 30 million Americans, in part by adding 17 million people to Medicaid.

But the impact of the high court’s ruling making the expansion voluntary is likely to be compounded by another provision in the law that the justices left intact: In 2014, states are no longer barred from making it harder for adults to qualify for Medicaid.

Experts worry those two developments taken together could spur some states to reduce the number of people covered.

States could throw some low-income adults “into a black hole with nowhere to turn for coverage," said Deborah Bachrach, who was New York’s Medicaid director until 2010 and now is special counsel at Manatt, Phelps & Phillips, a New York law firm.

As a hypothetical example, if Mississippi opted out of the 2014 expansion of Medicaid, poor childless adults would not gain coverage in that state. At the same time, the state could roll back eligibility for parents with children who are currently enrolled, reducing the number of participants in the program.

State officials have not talked about cutting Medicaid eligibility since the decision. But in the last several years, many have sought to reduce the cost of the program by cutting providers’ rates and contracting with private managed care companies, among other strategies.

"It’s a perfectly reasonable concern" that states might make it more difficult for adults to qualify, said Sara Rosenbaum, health policy professor at George Washington University.

Since 2009, when Congress approved the federal stimulus law, which included additional Medicaid funding, states have been prohibited from reducing eligibility or increasing the cost-sharing requirement for people enrolled in Medicaid. The health law extended that prohibition until 2014, when the expectation was that every state would adopt the Medicaid expansion under the law to give everyone under 133 percent of federal poverty level access to Medicaid.

But the high court struck down the penalty for states that did not expand, saying the threatened loss of their existing federal Medicaid dollars was "coercive."

Another way states might choose to minimize their costs is by shifting people who are eligible for federal subsidies for private insurance out of the Medicaid program and into new online markets created by the law. That saves states money because the federal government pays the entire cost of the subsidies -- unlike Medicaid, where states share in the costs.

The federal subsidies are available for those with incomes from 100 percent of the federal poverty level ($23,050 for family of four), to 400 percent ($92,000 for a family of four).

States would have an incentive, then, to set eligibility for Medicaid at 100 percent of the poverty level – rather than at the law’s 133 percent (about $31,000 for a family of four) -- to minimize their financial exposure.

Pushing people just over the poverty level into the federal subsidy program could be enticing for cash-strapped states that today share in the costs of Medicaid with the federal government, said Douglas Holtz-Eakin, president of the conservative American Action Forum and a former director of the Congressional Budget Office.

Since last week, Republican governors in at least seven states have indicated they would be unlikely to expand Medicaid even though the federal government will pay all the costs from 2014 to 2017 and at least 90 percent of the costs after that. States have until next year to decide on the expansion, and some are expected to negotiate their own terms with the Obama administration before signing on.

"This is going to be a lengthy dance between the states and federal government," Rosenbaum said.

http://www.kaiserhealthnews.org/Stories/2012/July/03/states-could-cut-medicaid-rolls-after-ruling.aspx

Ramp Up Support in the Senate

From the National Association of Health Underwriters ( http://www.nahu.org )

Thursday the U.S. Supreme Court ruled 5 to 4 to uphold the Patient Protection and Affordable Care Act (PPACA). The individual mandate requiring Americans buy health insurance was deemed constitutional in the ruling. Yet changes were made to the Medicaid provisions of the law.

Given today’s landmark ruling, it is more important than ever for NAHU members (and those who are involved in the sale and servicing of health insurance) to engage their senators in support for revising the Medical Loss Ratio (MLR).

S. 2288, a bill to remove broker compensation from the MLR calculation, introduced by Mary Landrieu (D-LA) and Johnny Isakson (R-GA) has 9 cosponsors!

We are asking you to take a few minutes to contact your senators through Operation Shout! and ask them to cosponsor S. 2288, which will remove agent and broker commissions from the MLR calculation.

Take Action - Click Here: http://capwiz.com/nahu/issues/alert/?alertid=61516036

If you are not a member of NAHU, visit http://www.nahu.org to learn more - and I would like to encourage you to become a member of the professional association which does its best to advocate for its members and their clients.

Obama administration and states move forward to implement health care law

U.S. Department of Health & Human Services

News Division                                

202-690-6343

media@hhs.gov

www.hhs.gov/news

FOR IMMEDIATE RELEASE

Friday, June 29, 2012

Obama administration and states move forward to implement health care law

Administration makes resources available to help states implement Affordable Insurance Exchanges

Health and Human Services Secretary Kathleen Sebelius announced today a new funding opportunity to help states continue their work to implement the health care law -- the Affordable Care Act. When the law is fully implemented in 2014, the affordable insurance exchanges will provide people and small businesses with one-stop shops to find, compare and purchase affordable, high-quality health insurance. Today’s announcement makes more funding available to build all models of affordable insurance exchanges available to states. HHS also issued further guidance today to help states understand the full scope of activities that can be funded under the available grant funding as they work to build exchanges.

“The federal government and our state partners are moving forward to implement the health care law,” Secretary Sebelius said.  “This new funding opportunity will give states the resources they need to establish affordable insurance exchanges and ensure Americans are no longer on their own when shopping for insurance.”

The funding opportunity announced today will provide states with 10 additional opportunities to apply for funding to establish a state-based exchange, state partnership exchange, or to prepare state systems for a federally facilitated exchange.  To date, 34 states and the District of Columbia have received approximately $850 million in Exchange Establishment Level One and Level Two cooperative agreements to fund their progress toward building exchanges.  

Under the new announcement, states can apply for exchange establishment cooperative agreements through the end of 2014. These funds are available for states to use beyond 2014 as they continue to work on their exchanges. This ensures that states have the support and time necessary to build the best exchange for their residents.

The guidance HHS issued today provides information on the exchange-building activities that states can fund with establishment cooperative agreements. The guidance can be found at: http://cciio.cms.gov/resources/factsheets/hie-est-grant-faq-06292012.html.

  

HHS will conduct regional implementation forums in coming months to assist states and stakeholders on the work to be done in building exchanges, and to address their questions. HHS will also engage with tribes, tribal governments, and tribal organizations on how exchanges can serve their populations.

For more information on exchanges, including fact sheets, visit http://www.healthcare.gov/news/factsheets/2011/05/exchanges05232011a.html