Posts Tagged Medicare

STUDY: Opioid Abuse Drops When Doctors Check Patients’ Drug History

STUDY: Opioid Abuse Drops When Doctors Check Patients’ Drug History

ITHACA, N.Y. – There’s a simple way to reduce the opioid epidemic gripping the country, according to new Cornell University research: Make doctors check their patients’ previous prescriptions.

The most significant response to the opioid epidemic comes from state governments. Nearly every state now has a database that tracks every prescription for opioids like OxyContin, Percocet and Vicodin. Using these databases, doctors and pharmacists can retrieve a patient’s history to decide whether they are an opioid abuser before prescribing them drugs.

Such databases reduce opioid abuse among Medicare recipients – but only when laws require doctors to consult them, according to a Cornell health care economist and her colleague. Their study refutes previous research suggesting the databases have no effect on opioid abuse. The paper is forthcoming in the American Economic Journal: Economic Policy.

“The main issue is getting providers to change their prescribing behavior. The majority of opioids that people abuse start in the medical system as a legitimate prescription,” said co-author Colleen Carey, assistant professor of policy analysis and management in the College of Human Ecology. Her co-author is Thomas Buchmueller of the University of Michigan.

States that implemented a “must access” database saw a decline in the number of Medicare recipients who got more than a seven-months’ supply in a six-month period. And there was a decrease in those who filled a prescription before the previous prescription’s supply had been used.

“Doctor shopping” also dropped. Medicare opioid users who got prescriptions from five or more doctors – a common marker for “doctor shopping” – fell by 8 percent; the number of those who got opioids from five or more pharmacies declined by more than 15 percent.

On the flip side, Medicare patients appeared to evade the new regulations by traveling to a less-regulated state.

Although the study looked only at Medicare recipients, the findings are likely to translate to the general population, the researchers said. The effects were especially large for low-income disabled users and for those who obtain opioid prescriptions from a high number of doctors; both groups have the highest rates of misuse and abuse, Carey said.

The strongest effects were in states with the strictest laws, such as New York, which require doctors to check the opioid history of “every patient, every time.” But even states with laws requiring access only under certain circumstances reduced doctor shopping.

Until recently Medicare has had very few legislative tools to curtail the epidemic. And insurance companies have little incentive, because opioids are relatively cheap, costing about $1.60 per day in the study’s sample. And opioids don’t hit Medicare insurers in the bottom line, making up only 3 percent of their total drug costs, Carey said.

For information about the Medical Association prescription drug abuse awareness program, visit Smart & Safe.

Posted in: Smart and Safe

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Opinion: All Americans Need Access to Affordable, Quality Care

meigsEditorial contributed by John Meigs Jr., M.D., president of the American Academy of Family Physicians, member of the Medical Association Board of Censors, and a family physician in Centreville, Ala. Editorial reprinted by permission.

Since Election Day, health care analysts have tried to forecast the fate of our health care system. Much remains uncertain, but what is undisputed is the goal that all Americans must be able to obtain affordable, high-quality and efficient health care. This must be at the center of any national health care strategy. That’s why America’s family doctors are starting this new year by encouraging the Trump administration and the 115th Congress to focus on this essential priority.

The American Academy of Family Physicians has long supported and advocated for meaningful patient-centered health care for all, an underlying tenet of many health care reform proposals, including the 2010 Affordable Care Act. We recognize that our current health care system is not perfect and new approaches can certainly improve the law. However, the nearly 200 million Americans who currently have health care coverage through the individual, small group and employer-based markets — as well as Medicaid — should not have their coverage and insurance protections jerked out from underneath them.

Within any changes, the overarching policy must ensure everyone has access to health care. Because America’s family doctors see more than half a million patients a day, we know what policies and programs ensure access to consistent, comprehensive and preventive care, particularly for low-income individuals and families. Financial barriers to care have crumbled as a result of Medicaid, the Children’s Health Insurance Program and Medicare. Medicaid and CHIP currently enroll nearly 73 million children and low-income Americans. Medicare preserves access to care for nearly 56 million elderly and disabled people. Equally important, patients who have privately purchased health insurance — particularly those with high-deductible plans — must not have to overcome financial obstacles to receive care.

Patient-centered care is at the heart of health care reform, which is why we must have a payment system that rewards the value of care over the volume of services provided. Our nation’s policy must build on the Medicare Access and CHIP Reauthorization Act — or MACRA — to ensure family physicians in all practice settings can continue to practice patient-centered care.

Our lawmakers also must commit to building a physician workforce that can meet the growing demand for primary care. They must support efforts to maintain a steady pipeline of primary care physicians through graduate medical education reforms and extension of the community-based Teaching Health Center program that attracts students to family medicine.

Health care is a personal matter, which is why primary care is the foundation of our health care system. Time and time again, primary care physicians have been counted on to provide care to millions of Americans from all parts of the country — for they have proven their expertise to improve health outcomes while lowering costs.

It is imperative that we have national health policies that ensure all Americans can sustain a continuous relationship with their primary care physicians. The only way we can do this is with legislation and regulations that ensure all Americans, regardless of health or financial status, can get needed health care in a timely, efficient, affordable and personalized manner. America’s family doctors pledge our support in helping to achieve this vision.

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Medicare Releases 2017 Physician Fee Schedule Final Rule

Medicare Releases 2017 Physician Fee Schedule Final Rule

The Centers for Medicare and Medicaid Services released its final rule for its 2017 physician fee schedule payment policies, which updates payment policies and payment rates for services provided under the Medicare Physician Fee Schedule (PFS) starting Jan 1, 2017.

The 1,400-page 2017 final rule discusses changes to a number of new policies that reflect a broader agencywide strategy to enhance quality, spend smarter and improve Americans’ health.

Here are eight changes to note:

CMS will begin gathering data on postoperative visits. The final rule requires reporting of postoperative visits for high-volume/high-cost procedures by a sample of practitioners in practices with 10 or more physicians. Reporting is required for services related to global procedures provided on or after July 1, 2017.

Changes were made to provider and supplier requirements for Medicare Part C. Providers and suppliers will be screened and enrolled in Medicare to contract with a Medicare Advantage organization to provide items and services to those enrolled in Medicare Advantage health plans.

CMS finalized its proposal to expand eligible telehealth services. The additional codes include those for end-stage renal disease-related dialysis, advanced care planning and critical care consultations. The critical care consultations provided via telehealth will use the new Medicare G-codes.

CMS will improve data transparency. Medicare Advantage organizations use a bidding process to apply to participate in the Medicare Advantage program, and the bidding process will reflect the organization’s estimated costs to provide benefits to enrollees. Under the final rule, Medicare Advantage organizations are required to release data associated with these bids on an annual basis. CMS will also require Medicare Advantage organizations and Part D sponsors to release medical loss ratio data on a yearly basis to help beneficiaries make enrollment decisions.

The agency revised the methodology used to calculate geographic practice cost indices. CMS adjusts payments under the physician fee schedule to reflect local differences in practice costs using geographic practice cost indices. The agency will revise the methodology used to calculate GPCIs to increase overall physician fee schedule payments in Puerto Rico. The updates will be phased in over 2017 and 2018.

CMS finalized expansion of the Medicare Diabetes Prevention Program. The 2017 rule finalizes some aspects of the expanded model, but future rulemaking will address payment policies, program safeguards and other issues. CMS expects to begin payment for MDPP services in 2018.

CMS revised the billing codes to more accurately pay for primary care, care management and other cognitive specialties. Among the changes are new codes to pay primary care practices that use interprofessional care management resources to treat patients with behavioral health conditions.

Physician payment rates will increase by 0.24 percent in 2017. CMS arrived at this increase after accounting for a 0.5 percent increase required by the Medicare Access and CHIP Reauthorization Act and mandated budget neutrality cuts, according to the American Hospital Association.

For more information, please see Final Policy, Payment, and Quality Provisions in the Medicare Physician Fee Schedule for Calendar Year (CY) 2017

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2017 Chronic Care Management Changes and Outsourcing Chronic Care

2017 Chronic Care Management Changes and Outsourcing Chronic Care

Medicare’s shift towards value-based care means the traditional model of health care reimbursement has just had a major shakeup. With value-based care, providers’ payments are now based on the value of care physicians deliver to patients and their health outcomes.

Patients with chronic conditions often require greater care outside of the office. Beginning Jan. 1, 2015, The Centers for Medicare & Medicaid Services (CMS) began paying for Chronic Care Management (CCM) services. Requiring at least 20 minutes of non-face-to-face care, providers receive an average reimbursement of $42 per patient per month with two or more chronic conditions. CCM has grown in popularity and many providers are seeing the increase in revenue. However, a number of physicians are still struggling to incorporate chronic care management into their practice. While the CMS requirements of CCM may be overwhelming, chances are many physicians are already managing Medicare patients with two or more chronic conditions and not getting the extra reimbursement to help with the added care.

The 2017 Medicare Physician Fee Schedule rule was finalized on Nov. 2, 2016. Providers will see payment changes for care management services in 2017. There are several changes that CMS has proposed regarding chronic care management. These changes are set to make billing rules within CCM simpler as well as expand the payment for complex CCM, including patients with behavioral health conditions. The new fee schedule rule will offer a new set of codes for providing care management to those patients.

Highlights from the 2017 Medicare Physician Fee Schedule regarding CCM

  • Simplification of CCM billing rules
  • Payment for complex CCM patients (CPT code 99487)
  • Supervision requirement change for CCM by Rural Health Clinics (RHC) and Federally Qualified Health Clinics (FQHC)
  • Pay for non-face-to-face extended E & M services

Part of the simplification of the CCM billing rules means the possibility of no longer requiring a consent form from the patient, but rather the provider would simply document in the patient’s medical record that CCM information was provided to the patient. Another benefit of this final rule is that initiating visits no longer have to be face-to-face office visits, unless the patient is considered a new patient or the patient has not been seen within the year prior to commencement of CCM. However, if providers do initiate CCM on a face-to-face visit, they can use the new GPPP7 to bill for that visit and receive a higher payment of $63.68.

Along with these changes to CCM for 2017, there is also a 3.5 percent increase in the CCM payment rate for 2017. The current rate in 2016 for CPT code 99490 is $40.82. This increase would make the 2017 rate $42.21. For complex CCM payments (CPT code 99487), the proposed rate for 2017 is $92.66. The complex CCM, CPT code 99487 requires 60 minutes of non-face-to-face care per month. CMS has also proposed an add-on code for complex CCM (CPT 99489) for each additional 30-minute increments of non-face-to-face time, at a proposed 2017 rate of $46.87. Please note: reimbursement rates vary by region.

MediSYS has outsourced full-service CCM to ease the burden on providers of meeting the CCM requirements while saving providers time and resources to enhance patient care.

“Providers have been very responsive to outsource chronic care management services because of the additional help they receive that saves them time and brings in additional revenue,” explained Jennifer Woodward, director of operations with MediSYS.

Outsourcing your CCM solution can help you increase revenue and expand patient satisfaction as well as provide you better patient access through a broader clinical depiction. CCM will also prepare providers for 2017 and the changes that MACRA has implemented in the healthcare industry to improve patient care and focus on value-based quality goals.

“With MIPS starting next year, providers are working hard to prepare for the changes that coming. By outsourcing this portion of the program, it provides them more time to work on the other aspects of the quality payment program to report effective care coordination,” Woodward said.

For information on MediSYS electronic health records and practice management solutions as well as outsourcing CCM services, please contact MediSYS at and visit the website at MediSYS is an official partner with the Medical Association.

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What You Said About MACRA…

What You Said About MACRA…

Just a few weeks ago, the Department of Health & Human Services dropped the finalized Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule – a landmark new payment system moving health care to a merit-based payment system. The rule, weighing in at almost 2,400 pages, has garnered more than 4,000 public comments since its proposal in April, is scheduled to become effective Jan. 1, 2017. With so little time to prepare, we asked some of Alabama’s physicians what they think about MACRA.


“MACRA is a very complex law and will be a burden for many of our physicians. However, please remember that MACRA repealed and replaced the SGR, the flawed program where we all annually faced pay cuts of 20 percent and greater and were always at the mercy of Congress to provide relief that almost always came at the last minute. With MACRA, we have the stability of knowing what to expect, we have the potential of increased payments and even bonus payments along with the possibility of negative updates as well. If you participate in Pick-Your-Pace at any level of participation in 2017, you will avoid any potential penalties in 2019, the first year of MACRA implementation. The MACRA updates in 2019 start at +/- as much as 4 percent and go up slowly each year but come nowhere close to the 21 percent cuts we faced under SGR. MACRA is by no means perfect, but it does begin the Medicare transition from volume-based Fee-For-Service payments to a value-based payment system. I would encourage all physicians to participate in Pick Your Pace at whatever level you are able to accomplish in 2017 to avoid potential penalties in 2019. As we delve deeper into this law, stay tuned for future updates and recommendations.” – John Meigs Jr., M.D., Brent

“Because I see very little Medicare patients, I have not studied MACRA or MIPS other than to know it will be a burden to physicians and staff in time or expense to hire a third party to do the reporting requirements. For physicians like me that see little Medicare patients, but just enough (about 100 a year) to be required to do the reporting to be penalized, it is burdensome. I may take the penalty and then ultimately not see Medicare anymore because it isn’t cost efficient for my practice. The government is continually putting more costly regulations and requirements on physician practices pressuring the overall viability of a private practicing physician in the future. There will come a breaking point.” – McCain Ashurst, M.D., Montgomery

“They’re talking about a reduction in payments for failing to meet standards, but how do you assess that — what metric do you use? How do you assess quality? And there’s a lot of flippant interpretations of what they’ll pay.” – Clifford Black, M.D., Anniston, quoted in The Anniston Star

“We’ll just have to pay more attention to what we do … how often patients get treatment … show that patients are getting proper quality of care … if you do it enough it’ll eventually become second nature. But it is a slightly greater bureaucratic level on physicians. Generally, the quality of care is good right now … maybe there will be a 1 to 2 percent improvement.” – Todd Scarbrough, M.D., Anniston, quoted in The Anniston Star

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Death vs. Another Hospital Stay: Study Suggests Medicare Should Weigh Them Equally

Death vs. Another Hospital Stay: Study Suggests Medicare Should Weigh Them Equally

ANN ARBOR — In the last few years, American hospitals have focused like hawks on how to keep patients from coming back within a few weeks of getting out.

Driven by new Medicare penalties for such events, the effort has slowed a ‘revolving door’ of readmissions for heart attack, heart failure and pneumonia patients that costs the nation billions of dollars.

But, a new analysis suggests that Medicare should focus more on how well hospitals do at actually keeping such patients alive during the same time.

If hospitals got paid less when their patients died soon after a hospitalization, just like they get paid less when those patients end up back in the hospital, it would be a game-changer for one-third of hospitals, say researchers from the University of Michigan Medical School and VA Ann Arbor Healthcare System who published their findings in JAMA Cardiology.

According to the study, about 17 percent of hospitals are getting punished for excess readmissions, but are keeping patients alive more often than would be expected, and another 16 percent of hospitals essentially get rewarded for low readmission rates, but their patients are more likely to die in the first month after leaving their hospital beds.

In other words, some of the hospitals that get penalized for high readmissions are those that may actually do the best job at keeping patients alive – and vice versa.

Preventive incentives

If the penalties took both readmission and mortality into account, the Medicare system would save the same amount of money, but incentivize good outcomes more fairly, the researchers said.

“Under most circumstances, hospital patients would much rather avoid death than readmission,” said Scott Hummel, M.D., M.S., senior author of the new paper and a heart failure cardiologist. “But the incentive to prevent death in the first 30 days after a hospitalization is 10 times less than the incentive to prevent a return hospital visit.”

He and his colleagues hope their analysis will spark a conversation about how to fine-tune the Medicare system’s effort to encourage better performance by America’s hospitals.

Their work is based on data from 2014, the first year when hospitals could both be penalized for readmission rates that were higher than expected and earn a financial reward based on a mix of measures that include everything from 30-day death rates to how well patients rated the care they received and the hospital environment.

Under the current policy, hospitals can lose up to three percent of condition-related payments from Medicare for excess readmissions but can recoup only about 0.2 percent of such payments for having low mortality rates.

First author Ahmad Abdul-Aziz, M.D., an internal medicine resident at U-M, helped coordinate the data analysis using publicly available data from the Centers for Medicare and Medicaid Services, called CMS for short. Some of it was accessed via an online system created by Kaiser Health News, based on data from CMS. In all, data from 1,963 hospitals was included.

The authors, who also include senior team members Rodney Hayward, M.D., and Keith Aaronson, M.D., M.S., calculated a ratio for each hospital based on observed and expected readmissions and mortality in the first 30 days for heart attack, heart failure and pneumonia. Although other conditions were added to the readmission program in 2015 and 2016, they weren’t included because these diagnoses are not yet included in the reward program for low mortality rates.

All the data were adjusted for how sick each hospital’s patients were when they started, using standard methods that allow an apples-to-apples comparison. The socioeconomic status of each hospital’s patients, which can also affect patient outcomes but aren’t in a hospital’s control, wasn’t included because CMS hadn’t yet started taking it into account in 2014.

The authors don’t take issue with the idea of penalizing excess readmissions — though they do note that readmissions for any cause are included in the program, not just readmissions for the problem that sent the person to the hospital in the first place.

Admissions to any hospital within 30 days of discharge count against the hospital that the patient was discharged from, which may work against large hospitals that patients travel to for advanced care before returning to their home area.

Other researchers have shown there isn’t a tight link between a hospital’s 30-day readmission rate and the 30-day mortality rate for its patients with these conditions — suggesting that there’s more to the story when thinking about using them as measures of hospital quality.

The authors also call for continued improvement in risk models that will more precisely predict a patient’s risk of readmission, just like current, well-tested models to predict their risk of death.

Better tools would mean better ability to test a hospital’s actual performance against what might be expected based on their entire patient population. The researchers also plan to examine what kinds of hospitals are most likely to win or lose financially if the balance shifts between penalties for reducing readmissions and those for reducing early mortality.

“The misaligned incentives for preventing readmission and preventing death may help explain why some hospitals are doing really well on one, but not on the other,” said Hummel. “It’s important we continue to reduce preventable readmissions, but we need to watch out for unintended consequences too.

“Sometimes, a readmission might be a good thing — no one wants to see patients die because they should have been readmitted,” he added. “If financial penalties drive hospitals to figure out how to improve outcomes, increasing incentives to reduce early post-hospital deaths seems like a good place to start.”

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CMS Releases MACRA Final Rule

CMS Releases MACRA Final Rule

*Editor’s Note: The Medical Association will be studying the just-released MACRA rule and will be providing additional info as it becomes available. The Association and MGMA will co-host a free webinar, “MACRA: Essential Strategies in Economic Reform” on Nov. 7 from 12 p.m. to 1:30 p.m. Click here for more information.

On Oct. 14, the Department of Health & Human Services finalized a landmark new payment system for Medicare physicians that will continue reforming how the health care system pays for care. The rule, which since its proposal in April garnered more than 4,000 public comments, cements the two payment tracks already proposed and is scheduled to become effective Jan. 1, 2017.

First, physicians can participate in the Merit-Based Incentive Payment System track, which based payment of clinic performance, practice improvement, reporting and technology use. However, the final rule makes official the “pick-your-pace provision” allowing physicians a slower entry into the model if they are not quite prepared to handle all aspects of the program. To do that, CMS is offering physicians a flexible performance period at the beginning.

“It’s time to modernize the Medicare physician payment system to be more streamlined and effective at supporting high-quality patient care. To be successful, we must put patients and clinicians at the center of the Quality Payment Program,” said Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS). “A critical feature of the program will be implementing these changes at a pace and with options that clinicians choose. Today’s policies are designed to get all eligible clinicians to participate in the program, so they are set up for successful care delivery as the program matures.”

The rule, which weighs in at nearly 2,400 pages, is informed by a months-long listening tour with nearly 100,000 attendees and nearly 4,000 public comments. A common theme in the input HHS received was the need for flexibility, simplicity, and support for small practices. First, the new payment system creates two pathways. These paths let clinicians pick the right pace for them to participate in the transition from a fee-for-service health care system to one that uses alternative payment models that reward quality of care over quantity of services.

Clinicians will choose between two options:

  • The first path gives clinicians the opportunity to be paid more for better care and investments that support patients. It reduces existing requirements, while still emphasizing and rewarding quality care. In the first year, it also provides a flexible performance period, so that those who are ready can dive in immediately, but those who need more time can prepare for participation later in the year.
  • The second path helps clinicians go further by participating in organizations that get paid primarily for keeping people healthy. For example, they could be part of an Accountable Care Organization where clinicians come together to coordinate high-quality care for the patients they serve. When they get better health results and reduce costs for the care of their patients, the clinicians receive a portion of the savings.

While the AMA is in the process of fully analyzing the regulations, a first review revealed that CMS responded to many of the concerns expressed by physicians about the proposed rule issued last spring. For example:

  • Details are provided about the 2017 transition period announced in September. The only physicians who will experience payment penalties in 2019 are those who choose to report no performance data next year, and those who report for at least 90-days will be eligible for positive payment adjustments.
  • The low-volume threshold that exempts physicians from all performance reporting has been increased from $10,000 in annual Medicare revenue and less than 100 Medicare patients to $30,000 in revenue or 100 patients. CMS estimates that this change will exempt 32.5 percent of physicians and other clinicians from the program.
  • Performance reporting requirements have been further reduced, and the resource use component of the Merit-based Incentive Payment System (MIPS) has been reweighted to zero for 2017.

“We recognize, as described through many insightful comments, that many eligible clinicians face challenges in understanding the requirements and being prepared to participate in the Quality Payment Program in 2017,” Slavitt said in an executive summary of the rule. “As a result, we have decided to finalize transitional policies throughout this final rule with comment period, which will focus the program in its initial years on encouraging participation and educating clinicians, all with the primary goal of placing the patient at the center of the health care system. At the same time, we will also increase opportunities to join Advanced APMs, allowing eligible clinicians who chose to do so an opportunity to participate.”

Evolving Along with Payment Reform

CMS is building the Quality Payment Program to evolve along with the health care system. That’s why it facilitates participation in new payment models. The Affordable Care Act created the Center for Medicare and Medicaid Innovation (Innovation Center) to implement and scale the best ideas from the medical community to improve the quality of care for Medicare beneficiaries while lowering costs. Medicare has a plan for eligible beneficiaries to receive free diabetes prevention services, the quality of hip and knee replacements are being improved while lowering costs, and primary care clinicians are using flexibility to deliver the best outcomes with a payment system that rewards results. CMS intends to broaden opportunities for clinicians, including small practices and specialties, to participate in these kinds of initiatives. CMS is also reviewing reopening some existing Advanced Alternative Payment Models for application to allow more clinicians to join these types of initiatives. In 2018, CMS expects about 25 percent of eligible clinicians will be a part of the second path of Advanced Alternative Payment Models.

Providing Comprehensive Support to Physicians

To further support small practices, MACRA provides $20 million each year for five years to train and educate Medicare clinicians in small practices of 15 clinicians or fewer and those working in underserved areas. Beginning December 2016, local, experienced organizations will offer free, on-the-ground, specialized help to small practices using this funding.

Continuing to Listen

HHS is receiving feedback on the final rule with a comment period and will accept comments until 60 days after the final rule’s release date.

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