October 2018 - Medical Association of the State of Alabama

Archive for October, 2018

Study: Risky Sedative Prescriptions for Older Adults Vary Widely

Posted by admin on October 26, 2018

Despite years of warnings that older adults shouldn’t take sedative drugs that put them at risk of injury and death, a new study reveals how many primary care doctors are still prescribing them, how often, and where the practice is most prevalent.

Mapped out county by county, the nationwide study shows wide variation in prescriptions of the drugs known as benzodiazepines. Some counties, especially in the Deep South and rural western states, had three times the level of sedative prescribing as those with the lowest levels.

The study, published in the Journal of General Internal Medicine, also highlights gaps at the provider level: Some primary care doctors prescribed sedatives at a rate more than six times that of their peers.

Researchers found that top prescribers of drugs such as Xanax, Ativan and Valium also tended to be high-intensity prescribers of opioid painkillers.

The counties with the most intense sedative prescribing tended to have lower incomes, less-educated populations, and higher suicide rates, the study finds. They also overlap with other maps showing high county-level opioid painkiller prescribing.

“Taken all together, our findings suggest that primary care providers may be prescribing benzodiazepines to medicate distress,” says Donovan Maust, M.D., M.Sc., a geriatric psychiatrist from the University of Michigan who led the study with a team from U-M and the University of Pennsylvania.

“And since these drugs increase major health risks, especially when taken with opioid painkillers, it’s quite possible that benzodiazepine prescribing may contribute to the shortened life expectancies that others have observed in residents of these areas.”

Where prescriptions are highest

The study is based on data about all prescriptions written in 2015 by primary care providers for patients in the Medicare Part D prescription drug program. The researchers combined that information with county-level health and socioeconomic data from the County Health Rankings project, a project of the Robert Wood Johnson Foundation and University of Wisconsin.

In the single year studied, the 122,054 primary care providers included in the study prescribed 728 million days’ worth of benzodiazepines to their patients, at a cost of $200 million.

The states with the highest intensity of prescribing — which the researchers defined as prescription days of benzodiazepines relative to all prescribed medication days — were Alabama, Tennessee, West Virginia, Florida and Louisiana.

States with the lowest intensity were Minnesota, Alaska, New York, Hawaii and South Dakota.

Across all types of providers, primary care and otherwise, benzodiazepines accounted for 2.3 percent of all medication days prescribed to Part D participants by those providers that year.

Primary care doctors accounted for 62 percent of all benzodiazepine prescriptions. This confirms other findings that led Maust and his colleagues to focus on primary care providers in the new study. Previous studies have shown such providers account for the majority of benzodiazepines prescribed to older adults, a population much less likely than younger adults to see a psychiatrist.

Higher sedative prescription intensity was also associated at the county level with more days of poor mental health, a higher proportion of disability-eligible Medicare beneficiaries, and a higher suicide rate.

More about sedative risks

Benzodiazepines have often been prescribed to ease anxiety or insomnia, though several studies by Maust and others have shown that patients receiving the drugs often don’t have a formal diagnosis of either condition.

But the drugs come with a price: clouded thinking ability, higher risk of auto accidents, falls and fractures, and a tendency to hook patients into long-term use despite their intended use as a short-term treatment.

Benzodiazepines as a class are the second-most common group of drugs associated with medication-related overdose deaths, right behind opioid painkillers.

Such risks have landed benzodiazepines on the American Geriatric Society’s list of prescription drugs that people over age 65 should avoid, although their short-term use in treating anxiety or insomnia that haven’t responded to other options is still considered acceptable.

More about the study

To be included in the county-level study, a given primary care provider had to prescribe a benzodiazepine at least 10 times in 2015. The individual physician-level study looked at 109,700 doctors after excluding the 10 percent of prescribers who saw the fewest Medicare beneficiaries.

The researchers divided individual prescribers into four groups according to the intensity level of their benzodiazepine prescribing.

The range was large. For the lowest group, about 0.6 percent of total prescriptions were for benzodiazepines, compared with 3.9 percent for the highest-intensity group. That’s a 6.5-fold difference in benzodiazepine prescribing.

Those in the highest-intensity group were also likely to be high-intensity prescribers for opioids and antibiotics, and also for other drugs that have been classed as high-risk for older adults.

“That the same providers appear to be high-intensity prescribers of both medications is potential cause for concern,” says Maust.

Female primary care providers were less likely to be high-intensity benzodiazepine prescribers. The more years a physician had been in practice, the higher their chance of being a high-intensity prescriber.

Physicians with higher percentages of patients who were white or who received Extra Help payments available to low-income, low-resource patients under Part D of Medicare were also more likely to be high-intensity sedative prescribers.

Researchers could not see data down to the patient-level in the available Medicare data, so they couldn’t look at what conditions patients were listed as having, other clinical findings, or the patients’ individual social and economic status.

In addition to Maust, the research team included senior author Steven Marcus, Ph.D. of the University of Pennsylvania, and U-M Department of Psychiatry faculty L. Allison Lin, M.D., M.Sc., and Fred Blow, Ph.D. Maust, Lin and Blow are all members of the U-M Institute for Healthcare Policy and Innovation.

Funding for the work came from National Institutes of Health (AG048321, DA045705), the American Federation for Aging Research, the John A. Hartford Foundation, and the Atlantic Philanthropies.

Tags: benzo, opioid

Posted in: Opioid

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Alabama Medicaid Alert: Short-Acting Opioid Naïve Limits

Posted by admin on October 26, 2018

Effective Nov: 1, 2018, the Alabama Medicaid Agency will begin implementing limits on short-acting opiates for opioid naïve recipients. The Agency defines “opioid naïve” as a recipient with no opioid claim in the past 180 days.

Edit Details:

A 7-day supply limit for adults age 19 and older
A 5-day supply limit for children age 18 and younger
A maximum of 50 morphine milligram equivalents (MME) per day allowed on a claim for an opioid naïve recipient
Any claim for a short acting opioid for an opioid naïve recipient exceeding the maximum days’ supply limit or MME limit will be denied.
Claims prescribed by oncologists will bypass the edit.
Long term care and hospice recipients are excluded.
Refills of remaining quantities and/or new prescriptions filled within 180 days of the initial opioid naive claim will require an override.
Refills of remaining quantities of prescriptions that are partially-filled will be allowed per State and federal law* but will require an override through Medicaid. See below for more details from the State Board of Pharmacy.
For adults, the refill of the quantity remaining on the partial fill will not count towards the prescription limit if filled within 30 days of the original prescription. Monthly maximum unit quantities still apply.
Overrides for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria Booklet for information about override requirements. Please refer to the following link for more information regarding overrides for opioid naïve patients:http://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx.
A Recipient Information Sheet for prescribers and pharmacists to provide to recipients can be found athttp://www.medicaid.alabama.gov/content/4.0_Programs/4.3_Pharmacy-DME.aspx .

IMPORTANT: A recipient may not pay cash for the remaining amount over 7 days for the same prescription of a Medicaid-paid opioid claim (ie a single fill/dispense/claim may not be ‘split billed’ to both Medicaid and cash). If the prescription to be paid by Medicaid exceeds the drug’s limit allowed, an override may be requested. Only if the override is denied, then the excess quantity above the maximum unit limit is deemed a non-covered service, and the recipient can be charged as a cash recipient for that amount in excess of the limit. A prescriber must not write separate prescriptions, one to be paid by Medicaid and one to be paid as cash, to circumvent the override process. FAILURE TO ABIDE BY MEDICAID POLICY MAY RESULT IN RECOUPMENTS AND/OR ADMINISTRATIVE SANCTIONS. Source: Provider Billing Manual 27.2.3

Morphine Milligram Equivalents (MME) Information/Examples

Higher doses of opioids are associated with higher risk of overdose and death. Even relatively low dosages (20-50 MME per day) increase risk.1

Examples of MME calculations/day include:

10 tablets per day of hydrocodone/acetaminophen 5/325 = 50 MME/day
6 tablets per day of hydrocodone/acetaminophen 7.5/325 = 45 MME/day
5 tablets per day of hydrocodone/acetaminophen 10/325 = 50 MME/day
2 tablets per day of oxycodone 15 mg = 45 MME/day
3 tablets per day of oxycodone 10 mg = 45 MME/day
10 tablets per day of tramadol 50 mg = 50 MME/day
1 patch per 3 days of fentanyl 25mcg/hr = 60 MME/day

A link with more information regarding MME calculations is https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf .

*Partial Filling of Schedule II Medication: Per the Alabama State Board of Pharmacy website, there has been a change in federal law regarding partial filling of Schedule II controlled substance (CS). The Comprehensive Addiction and Recovery Act (CARA) of 2016 passed the United States Senate and was signed into law on July 22, 2016. CARA allows pharmacists to partially fill Schedule II CS. According to CARA, a prescription may be partially filled if: it is written and filled according to state and federal law; the partial fill is requested by the patient or prescribing practitioner; and the total quantity dispensed does not exceed the quantity prescribed. Remaining portions of partially filled prescriptions must be filled within 30 days of the original written prescription date. There is no single specified way to fill or bill prescriptions under the CARA update.2

1 https://www.cdc.gov/drugoverdose/prescribing/guideline.html
2 http://www.albop.com/FAQ.aspx

Override Requests
Pharmacy override requests for quantities exceeding the maximum days’ supply limit or MME limit may be submitted to Health Information Designs (HID). Please see the Pharmacy Override External Criteria instructions for information about override requirements at:

http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

The Override Request Form is to be used by the prescriber or the dispensing pharmacy when requesting an override. The form can be found at:

http://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.13_Pharmacy_Forms.aspx.

Providers requesting overrides by mail or fax should send requests to:

Health Information Designs (HID)
Medicaid Pharmacy Administrative Services
P. O. Box 3210 Auburn, AL 36832-3210
Fax: 1-800-748-0116
Phone: 1-800-748-0130

Incomplete requests or those failing to meet Medicaid criteria will be denied. If the prescriber believes medical justification should be considered, the prescriber must document this on the form or submit a written letter of medical justification along with the override form to HID. Additional information may be requested. Staff physicians will review this information.

Any policy questions concerning this provider ALERT should be directed to the Pharmacy Program at (334) 242-5050. Questions regarding override procedures should be directed to the HID help desk at 1-800-748-0130.

Tags: alert, Medicaid, opioid

Posted in: Medicaid

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When Is It Wise to Offer Patients a Reduced Fee Schedule?

Posted by admin on October 26, 2018

Some of our practice management roundtable participants are offering certain patients an opportunity to pay fees of less than the standard fee schedule for their care. Below we will discuss how they are reaching that decision and if it could be appropriate for your practice.

Some patients have no insurance coverage but want to pay for their care. For this group, there is logic to support a price which is less than the standard fee schedule, if that fee schedule is already set above the amounts paid by all insurance companies and Medicare. The fee reduction is based on an acknowledgment that billed fees for health care are generally set at higher amounts than the providers expect anyway, so some discounting is within reason. A problem occurs when your group’s fees are set at precisely the amounts paid by your largest payers and any discount reduces your fee to levels below what insurance companies or government payers pay you. This can get you into big trouble because those payers are willing to pay only your UCR or Usual and Customary Rate, and if you are regularly making a lower rate available to others, the large payers could ask for repayments. However, if your fee schedule is sufficiently high, a discount to an individual might still leave you with enough fee to protect against violating any “most favored nation” clause in your contract with an insurance company.

After this logic is used to support fee reductions to uninsured patients, can it also be applied to patients who are underinsured? Most employers have received significant annual increases in medical insurance premiums for coverage of their employees. As a result, the employers are modifying the coverage to increase the deductibles dramatically. In one client practice, the annual deductibles per person were raised from $750 to $5,000 after premiums increased 18 percent, 18 percent and 15 percent over the most recent three years. As a result, patients are presenting at medical offices with personal liability so great that they are not able to pay for care. Some administrators even indicate that patients are postponing needed care because of their inability to pay for it.

If a practice has made a decision to reduce fees for patients without coverage, and since many patients are facing large deductibles, those physician offices are extending discounts to insured patients who wish to personally pay a lower fee in full at the time of service. Under HIPAA, patients do have the right to pay for care and request that you not file a claim with their insurance company, but there are forms the patient must sign to correctly document this handling.

The danger associated with any discounting is the possibility that all the discounted dollars serve to reduce physician bonuses at year end. The practice overhead will not be reduced by reason of discounting. If these discounts are thought of as the last dollars collected, then they would have been available for MD payment at bonus time. However, if by discounting you are collecting patient payment monies that would otherwise have become a bad debt not collected, then the amounts you receive are incremental money for distribution to doctors at year end. Which of these situations applies to you will depend on whether your group is writing off uncollected patient balances that could have been obtained, in part, at the time of service.

So what is the take away relative to this trend? First, have a practice which is so well known for excellence in care that you may pick the patients you want and avoid discounting fees to anyone. Next, make sure your standard fee schedule is set higher than the reimbursement you receive from your practice’s highest payer. Finally, reach an agreement among all of your physicians on the discounting process you want to consistently apply and implement that process by training all staff. Times are changing in health care and one major change is the shifting of cost risks to the patients from their insurance carriers. Be sure your practice is adapting to this area of change.

Article contributed by Sae Evans, Maddox Casey and Jim Stroud, Members, Warren Averett Healthcare Consulting Group. Warren Averett is an official Gold Partner with the Medical Association.

Tags: fee, Insurance, management, schedule

Posted in: Management

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President Signs Bills Lifting Pharmacist ‘Gag Clauses’ on Drug Prices

Posted by admin on October 18, 2018

Earlier this week, President Trump signed two bipartisan bills into law that will allow pharmacists to tell patients they can save money on drugs by paying cash or trying a lower-cost alternative. At issue was the “broken” drug pricing system in the U.S. that was forcing patients to make decisions, which could have negatively impacted their health.

The bills, the Patient Right to Know Act and the Know the Lowest Price Act, prohibit health insurers and pharmacy benefit managers from using “gag clauses” that prevent pharmacists from sharing with patients the lower-cost options when they are purchasing medically necessary medication. In addition, the legislation ensures the Federal Trade Commission will have the necessary authorities to combat anti-competitive pay-for-delay settlement agreements between manufacturers of biological reference products and follow-on biologicals. The Patient Right to Know Act would apply similar “gag clause” protections to Medicare and MA plans.

Under the new legislation, pharmacists will be allowed, though not required, to tell patients about lower-cost options. If pharmacists don’t tell, then patients will have to ask about the cost of the medication. However, some pharmaceutical industry experts say although eliminating the gag clause is a step toward consumer transparency, it doesn’t address the issue of lowering actual drug costs, making it unclear how much of a tangible effect the legislation will have.

According to research published in JAMA in March, people with Medicare Part D drug insurance overpaid for prescriptions by $135 million in 2013. Copayments in those plans were higher than the cash price for nearly 1 in 4 drugs purchased in 2013. For 12 of the 20 most commonly prescribed drugs, patients overpaid by more than 33 percent.

Yet some critics say eliminating gag orders doesn’t address the causes of high drug prices. “As a country, we’re spending about $450 billion on prescription drugs annually,” said Steven Knievel, who works on drug price issues for Public Citizen, a consumer advocacy group. The modest savings gained by paying the cash price “is far short of what needs to happen to actually deliver the relief people need.”

Tags: advocacy, gag, low, patient, pharmacy, Price

Posted in: Advocacy

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POLL: Rural Americans “Profoundly Worried” about Opioid Crisis

Posted by admin on October 18, 2018

BOSTON — According to a new NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health poll, rural Americans cite drug/opioid abuse as the biggest problem facing their local community (25 percent), followed by economic concerns (21 percent).

The poll of 1,300 adults living in the rural United States found that a majority of rural Americans (57 percent) say opioid addiction is a serious problem in their community, and about half (49 percent) say they personally know someone who has struggled with opioid addiction. “What has been widely recognized is the serious economic problems facing rural communities today. What has not is that drug/opioid abuse in rural communities is now viewed with the same high level of concern as economic threats,” said Robert J. Blendon, co-director of the survey and the Richard L. Menschel Professor of Health Policy and Political Analysis at Harvard T.H. Chan School of Public Health.

On economic issues, rural Americans largely hold negative views of their local economy, but nearly one-third have seen economic progress in recent years. A majority of rural Americans (55 percent) rate their local economy as only fair or poor, while over the past five years, 31% say their local economy has gotten better, and 21 percent say it has gotten worse.

Rural Americans are divided over whether they expect the major problems facing their communities will be solved in the near future, and a majority believe outside help will be necessary to solve these problems. About half of rural Americans (51 percent) say they are confident that major problems facing their local community will be solved in the next five years, and 58 percent believe their community needs outside help to solve its major problems. Among those who say their community needs outside help, about six in ten rural Americans (61 percent) think the government will play the greatest role in solving major problems facing their local community.

In addition, many rural Americans are optimistic about the future. A majority of rural parents (55 percent) think their children will be better off financially than themselves when their children become their age. “There is no single vision of life in small-town America, just as there is no one-size-fits-all solution to improving health,” said Richard Besser, president and CEO of the Robert Wood Johnson Foundation. “But we see in this diversity a common thread — an understanding that health and wellbeing means many things: better access to health care, good job opportunities, and quality education for all.”

View the complete poll findings.

Key Findings

Many rural Americans are optimistic about future jobs

Many rural Americans are optimistic about future job opportunities, but they recognize new training and skills may be important for the future rural workforce. Looking ahead five years, 39 percent of rural Americans believe the number of good jobs in their local economy will increase, while 47% believe they will stay the same.

About one-third of rural Americans (34 percent) say it will be important for them to get training or develop new skills in order to keep their job or find a better job in their local community in the next five years, including 25 percent of all rural adults who say they will need computer and technical skills and 24% who say they will need a first or more advanced educational degree or certificate.

Education, job growth, and health care will improve rural economies

When it comes to improving their local economy, a majority of rural Americans think the following approaches would be very helpful: creating better long-term job opportunities (64 percent), improving the quality of local public schools (61 percent), improving access to health care (55 percent), and improving access to advanced job training or skills development (51 percent). (See table below.)

Rural Americans’ Views on Approaches to Improving the Local Rural Economy

Q44. Recently, a number of leadership groups have recommended different approaches for improving the economy of communities like yours. For each of the following, please tell me how helpful you think this approach would be for improving the economy of your local community…[insert item]. Do you think this would be very helpful, somewhat helpful, not too helpful, or not at all helpful?

	Percent saying “very helpful”
1. Creating better long-term job opportunities	64%
2. Improving the quality of local public schools	61%
3. Improving access to health care	55%
4. Improving access to advanced job training or skills development	51%
5. Improving local infrastructure like roads, bridges, and public buildings	48%
6. Improving the use of advanced technology in local industry and farming	44%
7. Improving access to small business loans and investments	44%
8. Improving access to high-speed internet	43%

NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health, Life in Rural America, 6/6/18 – 8/4/18. Q44. Questions asked among a half-sample of respondents: Half Sample A N=669, Half Sample B N=631 rural adults ages 18+.

There are sizable gaps between how minorities and non-minorities believe people are treated in rural communities

Despite low recognition of discrimination against minority groups in their local community by all rural Americans, rural adults belonging to several minority groups see much higher rates of discrimination against members of their group. For example, only 21 percent of all rural Americans say that generally speaking, they think Latinos are discriminated against in their local community, yet 44 percent of Latinos living in rural areas say they think Latinos are discriminated against in their local community. A majority of Latinos (56 percent) also say they think recent immigrants are discriminated against in their local community, compared to 29 percent of all rural Americans who share this view.

*Not enough cases for analysis. NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health, Life in Rural America, 6/6/18 – 8/4/18. Q19. Total N=1,300 rural adults ages 18+.

Methodology

The poll in this study is part of an on-going series of surveys developed by researchers at the Harvard Opinion Research Program (HORP) at Harvard T.H. Chan School of Public Health in partnership with the Robert Wood Johnson Foundation and National Public Radio. The research team consists of the following members at each institution.

Harvard T.H. Chan School of Public Health: Robert J. Blendon, Professor of Health Policy and Political Analysis and Executive Director of HORP; John M. Benson, Senior Research Scientist and Managing Director of HORP; Mary T. Gorski Findling, Research Associate; Logan S. Casey, Research Associate in Public Opinion; Justin M. Sayde, Administrative and Research Manager.

Robert Wood Johnson Foundation: Carolyn Miller, Senior Program Officer, Research and Evaluation; and Jordan Reese, Director of Media Relations.

NPR: Andrea Kissack, Senior Supervising Editor, Science Desk; Joe Neel, Deputy Senior Supervising Editor, Science Desk; Vickie Walton-James, Senior Supervising Editor, National Desk; Laura Smitherman, Deputy Senior Supervising Editor, National Desk; Luis Clemens, Supervising Editor, National Desk; Ken Barcus, Midwest Bureau Chief.

Interviews were conducted by SSRS of Glen Mills (PA) via telephone (including both landline and cell phone) using random-digit dialing, June 6 – August 4, 2018, among a nationally representative probability-based sample of 1,300 adults age 18 or older living in the rural United States. Interviews were conducted in English and Spanish. The margin of error for total respondents is ±3.6 percentage points at the 95% confidence level. The sample of Rural Americans is defined in this survey as adults living in areas that are not part of a Metropolitan Statistical Area (MSA). This is the definition used in the 2016 National Exit Poll.

Possible sources of non-sampling error include non-response bias, as well as question wording and ordering effects. Non-response in telephone surveys produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases and for variations in probability of selection within and across households, sample data are weighted by cell phone/landline use and demographics (sex, age, education, and Census region) to reflect the true population. Other techniques, including random-digit dialing, replicate subsamples, and systematic respondent selection within households, are used to ensure that the sample is representative.

Tags: foundation, harvard, opioid, poll, rural

Posted in: Opioid

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PIPA Open Enrollment During October

Posted by admin on October 12, 2018

The Physicians Insurance Plan of Alabama through Blue Cross Blue Shield is available for qualified* members of the Medical Association providing you, your family and staff with strong benefits at affordable premiums as compared to other options. The PIPA health coverage rates for 2019 will have a decrease of 4.5 percent and dental coverage has decreased by 5.3 percent.

Qualified members may sign up for insurance when full Regular Member dues are paid. Your membership dues alone could save you thousands in insurance premiums and out-of-pocket expenses. The PIPA plan does not require all participants in your office be on the same plan.

Let our dedicated staff provide you with one-on-one personal assistance with all your Blue Cross and Blue Shield of Alabama policy needs.

Open enrollment for PIPA is Oct. 1- Oct. 31 for a Jan. 1, 2019, effective date. If you are currently enrolled in PIPA, you do not have to reapply. However, if you or your employees wish to make changes to your current plan, please do so no later than Oct. 31, 2018. You will be billed for the first quarter of 2019 at the beginning of December.

New for 2019

HSA Plan Now Offered

PIPA has added a third health insurance option, which is a High Deductible Plan that can be used in conjunction with a Health Savings Account (HSA). Rates for the high-deductible plan and further information regarding how to set up an HSA account can be found at www.alamedical.org/insurance.

Practices that elect to offer the HSA option will need to “opt in” to the plan by signing the HSA notice agreement on the website and returning it to Brenda Green. Practices will be responsible for the administration of the HSA for their employees as this will be a separate function from the services provided by the Medical Association. The Association will enroll individuals in the Blue Cross high-deductible plan as is currently done with the other plans, and the practice will be responsible for setting up the HSA administration.

If you are currently enrolled in PIPA and wish to continue with no changes, you are not required to take any further action (Premium invoices will be mailed the first week in December). If you or your employees wish to make changes to your current plan, please do so no later than Oct. 31, 2018 (the last day of open enrollment).

If you have any questions, please contact Brenda Green at (334) 954 2514 or toll free at (800) 239-6272. You may also e-mail her at bgreen@alamedical.org.

How to apply

Complete the Application for Insurance
Complete an Employer Participation Agreement (one per entity)
Complete the Cover Page indicating the type of coverage for each application (High, Basic or Dental)
Submit the premium amount plus a $10 application fee (per application)
Applications will be processed when all information is received, 2019 dues requirements are met by all physicians applying, and all monies have been paid.

Learn more on our website

Visit www.alamedical.org/insurance for full details of the plan and for links to applications and materials. For more information call Brenda Green at (800) 239-6272, e-mail her at bgreen@alamedical.org, or visit www.alamedical.org/insurance to learn more about health insurance with the Medical Association.

*See the Eligibility Decision Tree on our website for guidance. Visit www.alamedical.org/insurance.

Tags: BCBS, Insurance, PIPA

Posted in: Insurance

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CMS Updates LCD Determination Process

Posted by admin on October 12, 2018

On Oct. 3, 2018, the Centers for Medicare and Medicaid Services announced updates to Chapter 13 of the Medicare Program Integrity Manual, which deals with Local Coverage Determinations. According to CMS, the updates are intended to “increase transparency and patient engagement.”[1] These changes call for informal meetings with interested parties before a formal request is submitted to the Medicare Administrative Contractor. Educational meetings can be held in local jurisdictions and can be either in-person, teleconference or web-based. Additionally, the changes to the manual set forth a roadmap for how the MAC issues an LCD.

LCDs are issued by MACs when there is no national determination on whether an item or service is covered. The idea is that the regional MACs will take into account local variations in the practice of medicine when issuing the LCD. For example, Palmetto GBA, Alabama’s MAC for Medicare Part A and B has issued an LCD on allergy testing (L33417).

According to a Medicare Learning Network publication[2], CMS’s updates were a result of feedback from providers and healthcare associations who were concerned that beneficiaries were not receiving necessary products and procedures due to deficiencies in the LCD process, such as notification of revisions to and drafting of LCDs. The new LCD process is intended to allow for more interaction with stakeholders before and during LCD development.

The “Roadmap”

1) Requests for LCD

MACs will consider requests from beneficiaries residing or receiving care in the MAC’s jurisdiction, health care professionals doing business in the MAC’s jurisdiction or any interested party doing business.

A request is deemed complete if the request:

Is in writing and is sent to the MAC via e-mail, facsimile or written letter.
Clearly identifies the statutorily-defined Medicare benefit category to which the item or service applies.
Identifies the language the requestor wants in an LCD.
Includes justification supported by peer-reviewed evidence. Full copies of the published evidence must be included.
Addresses relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service.
Fully explains the design, purpose, and/or method as appropriate of using the item or service for which the request is made.

2) Consideration of the LCD

The new guidelines suggest that MACs supplement the requests or proposed LCDs with clinical guidelines, consultation with experts, medical associations or other health care professionals. This information is to be summarized prior to drafting or finalizing the LCD.

3) Publication

A proposed LCD will be published on the Medicare Coverage Database (MCD) website at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Once published, MACs will allow 45 days for public comment. There are some exceptions to the publication requirement.

4) Contractor Advisory Committee (CAC)

A CAC will be established from each state and will be composed of healthcare professionals, beneficiary representatives and representatives of medical organizations. The purpose of the CAC is to assist in the evaluation of the evidence in developing LCDs and communicate between the MACs and healthcare community. This is an advisory committee with the ultimate authority residing with the MACs.

5) Open Meetings

After the LCD publication, the MAC will hold an open meeting to discuss the rationale and evidence supporting the LCD. Interested parties can also make presentations at these meetings. The date and location of the meetings must be publicized by the MAC.

6) Publication of Final Determination

After the close of the comment period and the required public meeting, the final LCD and Response to Public Comment will be published on the MCD (see link above). MACs must respond to all comments received during the comment period.

7) Notice Period

The date the final LCD is published on the MCD marks the beginning of the required notice period of at least 45 days before the LCD can go into effect. If the notice period is not extended by the MAC beyond the 45 days, the LCD is effective on the 46th calendar day.

Additional changes include the retirement (or expiration) of all proposed polices if not finalized within one year after the original posting date and a removal of all ICD and CPT codes from LCDs.

For more information on the changes to Chapter 13, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.

[1] CMS Accelerates Innovation and Promotes Patient Access to Medical Technology, https://www.cms.gov/newsroom/press-releases/cms-accelerates-innovation-and-promotes-patient-access-medical-technology

[2] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Angie Cameron Smith is an attorney at Burr & Forman LLP practicing within the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

Tags: CMS, engagement, patient

Posted in: CMS

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Does Your Workforce Know Its Privacy/Security Officials? They Better.

Posted by admin on October 12, 2018

As a health care compliance attorney for more than 12 years, I may not have seen it all, but I’ve definitely seen a lot. An unfortunate, yet common, pattern is a lack of compliance with some of the most basic state and federal regulations. There are some documents and practices that are required to be compliant with the Health Insurance Portability and Accountability Act. These are considered to be a part of the entity’s basic HIPAA infrastructure. When entities fail to provide evidence of these basic elements of a HIPAA-compliant program, one must ask themselves if that entity is unable or unwilling to follow the regulations.

One of the most common issues is an entity’s failure to show evidence of their HIPAA Privacy and Security Officer designations. Health care providers are specifically required to designate Privacy and Security Officials. These individuals are responsible for developing HIPAA policies and procedures for the entity and ensuring adherence to the regulations.[1] These designations must be in writing.[2]

Privacy Officer Designee

The Privacy Officer is responsible for developing and implementing HIPAA policies and procedures. These responsibilities include ensuring that the entity is compliant with the HIPAA Privacy Rule and Breach Notification Rule, as well as other applicable state and local laws. Their duties may include, but are not limited to, the following:

Receiving and appropriately addressing complaints relating to protected health information (PHI) and electronic protected health information (ePHI);
Receiving and processing requests made in accordance with Patient’s Rights and the Notice of Privacy Practices;
Ensuring that the workforce is receiving adequate HIPAA training annually and refresher training, when applicable;
Recommending disciplinary action for workforce members who violate HIPAA regulations;
Oversight of Business Associate relationships and Business Associate Agreements; and
Ensuring that HIPAA-related documents are maintained by the entity for a period of at least six (6) years.

Security Officer Designee

The Security Officer is responsible for ensuring that the entity is compliant with the HIPAA Security Rule and the development and implementation of HIPAA policies and procedures that relate specifically to ePHI. Their duties include, but are not limited to:

Ensuring the confidentiality, availability and integrity of ePHI;
Developing, implementing and enforcing information security directives mandated by HIPAA regulations;
Ensuring that an appropriate and adequate Risk Analysis is performed, at least annually;
Developing or updating the entity’s Business Continuity Plan;
Ensuring the adequacy of the entity’s Disaster Recovery and Incident Response plans; and
Ensuring that HIPAA-related documents are maintained by the entity for a period of at least six (6) years.

It is also worth noting that the Alabama Breach Notification Act of 2018 also requires the designation of a Security Official. The statute specifically requires that covered entities designate “an employee or employees to coordinate the covered entity’s security measures to protect against a breach of security.”[3]

Workforce Members Should Readily Identify Privacy and Security Officials

It is extremely important that workforce members be able to readily identify the Privacy and Security Officials for their entity. It is necessary for them to know whom they should consult for several reasons. First, if they have questions regarding the HIPAA policies and procedures, they should know who they should turn to in order to gain clarity. Second, as HIPAA-related complaints arise, it is necessary for them to identify individuals within their entity who can resolve those complaints in a manner that is both helpful to the complainant and in accordance with the regulations. Often, if matters can be resolved by the Privacy or Security Officers then patients/clients won’t find it necessary to contact the Department of Health and Human Services (HHS) to address their issue(s). Third, when workforce members know with whom to discuss HIPAA-related matters, it provides the opportunity for Privacy and Security Officials to gain a broader understanding of the HIPAA Privacy and Security issues within their organization. Instead of workforce members attempting to resolve issues based on their limited understanding of the regulations, they instead have a point of contact who can appropriately address their issues and ensure that HIPAA-related matters are addressed with an appropriate level of consistency within the organization.

Privacy and Security Officers Often Wear Multiple Hats

Health care providers must designate Privacy and Security Officers regardless of the size of the organization. Larger organizations normally have Privacy and Security Officials who serve in those capacities full-time. Smaller entities, more often than not, assign these responsibilities to individuals who have other job functions. Examples include an office manager, information technology professional or other designee the entity determines can adequately handle the responsibilities.

It is important that all health care entities ensure that they have not simply considered personnel to fill the role of the Privacy and Security Officials within their organization, but that those designations are in writing and communicated to their workforce. These individuals should receive adequate and on-going training to ensure that they are abreast of any changes to state or federal regulations that may impact their entity.

For additional information on Privacy and Security Officer Designations or for assistance with drafting job descriptions for these individuals, health care providers should consult a health care compliance professional.

[1] §164.530 (a)(1)

[2] §164.530 (a)(2)

[3] SB318 Section 3(c)(1)

Article by Samarria Dunson of The Dunson Group. The Dunson Group is a partner of the Medical Association.

Tags: HIPAA

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Association Announces New Online, OnDemand Education Center

Posted by admin on October 12, 2018

Did you know that as a member of the Medical Association, you have access to our new online, OnDemand Education Center? Featured are seven Alabama Opioid Prescribing courses that meet the Alabama Board of Medical Examiner requirements for holders of an ASCS and are FREE to Medical Association members.

The Medical Association’s new OnDemand Education Center is easily accessed through our website, www.alamedical.org/onlinecme. Simply sign in using your Medical Association username and password and add course(s) to your shopping cart.

“We joined this partnership as a way to bring our members the best educational courses available at the click of a button,” said Executive Director Mark Jackson. “Being a physician is a lifelong learning experience, and we wanted to deliver that opportunity in the easiest, most affordable way possible to Alabama’s physicians and other health care providers. This program was designed for physicians who are busy and have little time to spare but who want to continue expanding their educational prospects to the best of their abilities. Our new online, OnDemand learning experience provides an exciting venue to learn from our own courses in the catalog as well as from others across the country.”

Included in the OnDemand package are the seven Alabama Opioid Prescribing Courses, which meet the CME requirements for the Alabama Board of Medical Examiners:

Mitigating Risk When Prescribing Opioids
Resist the Opioid Pendulum: Understanding Opioids and Pain and How They Relate to Addiction
Use and Misuse of Benzodiazepines
Fighting the Opioid Crisis: The Prescription Drug Monitoring Program (PDMP)
Basic Principles and Advanced Concepts in Pain Management
CDC Guidelines for Prescribing Opioids for Chronic Pain
Issues from the Alabama Board of Medical Examiners

OnDemand courses are contributed not only by the Medical Association but also other medical associations and societies across the country. Categories currently include:

Addiction
Alabama Opioid Prescribing
Prescribing
Specialty-specific Topics
Billing and Coding
Ethics
Family Medicine
HIPAA
ICD-10
Internal Medicine
Legal
Medical Staff Leadership
Medico-Legal
Obesity

Opioid Prescribing
Pain Management
Patient Safety
Physician Health
Practice Management
Primary Care
Public Health
Regulatory and Compliance
Risk Management
Substance Abuse
Technology
Tobacco
Women’s Health

Click here to go to the OnDemand Education Center. Log in using your Medical Association username and password. For more information about the new OnDemand Education Center, contact the Education Department at (800) 239-6272.

Tags: education, ondemand, online, prescribing

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Stay Safe During Hurricane Michael

Posted by admin on October 10, 2018

As Hurricane Michael takes aim at Alabama, all families in affected areas should take health and safety precautions in connection with tropical storm force winds associated with the storm. Listen and follow all health and safety warnings communicated through the news media, and below are some tips to stay safe during the next few days.

Food Safety

Power outages associated with tropical storm force winds can cause concerns about the safety of frozen and refrigerated foods. As a general rule, a full upright or chest freezer will keep foods frozen for about two days without power.

A partially full freezer will keep foods frozen for about one day. This time may be extended by keeping the door shut. A refrigerator will keep foods cool for four to six hours if the door is kept closed as much as possible.

Any thawed foods that have been at room temperature for more than two hours should be discarded. Foods still containing ice crystals can be refrozen, although the quality of the food may decrease. Foods that have thawed to refrigerator temperatures (that is, no more than 40 degrees Fahrenheit) can also be cooked and then refrozen.

Carbon Monoxide

The public should never use generators, grills, camp stoves or other gasoline, propane, natural gas, or charcoal-burning devices inside a home, basement, garage or camper–or even outside near an open window. Keep these devices at least 20 feet away from any door, window or vent and also use a battery-operated or battery back-up carbon monoxide (CO) detector any time you use one of these devices.

CO is an odorless, colorless gas that can cause sudden illness and death if breathed. When power outages occur during emergencies such as hurricanes, people often try to use alternative sources of fuel or electricity for heating, cooling or cooking. CO from these sources can build up in a home, garage or camper and poison the people and animals inside. Look to friends or a community shelter for help. If you must use an alternative source of fuel or electricity, be sure to use it only outside and away from open windows.

Exposure to carbon monoxide can cause loss of consciousness and death. The most common symptoms of CO poisoning are headache, dizziness, weakness, nausea, vomiting, chest pain and confusion. People who are sleeping or who have been drinking alcohol can die from CO poisoning before ever having symptoms. Consult a health care professional right away if these symptoms occur.

Important Tips

Never use a charcoal grill, hibachi, lantern or portable camping stove inside a home, tent or camper.
Never run a generator, pressure washer or any gasoline-powered engine inside a basement, garage or other enclosed structure, even if the doors or windows are open, unless the equipment is professionally installed and vented. Keep vents and flues free of debris, especially if winds are high. Flying debris can block ventilation lines.
Always set up a generator at least 20 feet from your home, doors, windows, and vents. Follow the advice linked here:
a. English:https://www.cdc.gov/co/pdfs/generators.pdf
b. Spanish:https://www.cdc.gov/co/pdfs/flyers_Spanish.pdf
Never run a motor vehicle, generator, pressure washer or any gasoline-powered engine outside an open window or door where exhaust can vent into an enclosed area.
Never leave the motor running in a vehicle parked in an enclosed or partially enclosed space, such as a closed garage.

Animals

Stray animals can pose a danger during a storm. Most animals are disoriented and displaced, so do not corner an animal. Certain animals may carry rabies; therefore, care should be taken to avoid contact with strays. Although rabies is rare, it may be transmitted in Alabama by foxes, bats, raccoons or rarely other animals. If you are bitten by an animal, seek immediate medical attention as soon as possible. If an animal must be removed, contact your local animal control authorities.

Injury Prevention

The public should follow these safeguards against injury while using a chain saw:

Operate, adjust and maintain the saw according to manufacturer’s instructions provided in the manual accompanying the chain saw.
Properly sharpen chain saw blades and properly lubricate the blade with bar and chain oil. Additionally, the operator should periodically check and adjust the tension of the chain saw blade to ensure good cutting action.
Choose the proper size of chain saw to match the job, and include safety features such as a chain brake, front and rear hand guards, stop switch, chain catcher and spark arrester.
Wear the appropriate protective equipment, including hard hat, safety glasses, hearing protection, heavy work gloves, cut-resistant leg wear (chain saw chaps) that extend from the waist to the top of the foot, and boots which cover the ankle.
Avoid contact with power lines until the lines are verified as being de-energized.
Always cut at waist level or below to ensure that you maintain secure control over the chain saw.
Bystanders or coworkers should remain at least two tree lengths (at least 150 feet) away from anyone felling a tree and at least 30 feet from anyone operating a chain saw to remove limbs or cut a fallen tree.
If injury occurs, apply direct pressure over site(s) of heavy bleeding; this act may save lives.

For Downed Power Lines

If power lines are lying on the ground or dangling near the ground, do not touch the lines. Notify your utility company as soon as possible that lines have been damaged, or that the power lines are down, but do not attempt to move or repair the power lines.

Avoid driving through standing water if downed power lines are in the water. If a power line falls across your vehicle while you are driving, continue to drive away from the line. If the engine stalls, do not turn off the ignition. Stay in your vehicle and wait for emergency personnel. Do not allow anyone other than emergency personnel to approach your vehicle.

For more information on hurricane safety, please visit www.alabamapublichealth.gov.

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