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In April the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was signed into law. The new law did away with the sustainable growth rate (SGR) formula that had been used to calculate Medicare Part B payments to physicians.

Why it matters to ACP members

The SGR was a flawed formula put in place to attempt to control costs by tying Medicare payments to growth in the overall economy, without regard for the cost of providing care. For over a decade the SGR formula had caused chaos in Medicare payments to physicians, repeatedly threatening double-digit cuts that grew with each threat.

How did ACP help you?

Beginning in 2002 ACP was hard at work advocating with Congress to stop the threatened cuts, while also trying to focus attention on the need to stop “kicking the can down the road” and find a long-term fix to the annual problem. ACP told Congress that this annual game took attention of real improvements that could be made to the physician payment system. We advocated for a long-term fix that would move physician payments away from incentivizing volume of care toward payments that would focus on the value of care provided. Many of ACP’s ideas found their way into MACRA, which was passed with bipartisan support in both the House and Senate.

MACRA will now provide a stable payment environment for physicians moving forward as we begin the transition toward a system focused on quality of care. Now ACP’s advocacy moves toward ensuring that this new law is implemented as smoothly as possible for physicians. ACP has already provided input to the Centers for Medicare and Medicaid Services as they begin writing the regulations that will give us the details of how the law will work, and we will continue to try and make improvements for internists as we move along the process of implementing the new law.

What other improvements will internists see under MACRA?

As MACRA moves us toward a value-based system it will majorly revamp Medicare’s existing quality and value programs: the Physician Quality Reporting System, the Value-Based Payment Modifier, and the Medicare EHR Incentive Program (Meaningful Use). The programs will be combined into the Merit-Based Incentive System (MIPS), one of two payment pathways that physicians can choose under the new system. This new system will simplify the administrative burden by consolidating and harmonizing the deadline, incentive payments and measures across the existing programs.

Under MACRA physicians could also choose to take the Alternative Payment Model (APM) pathway. This model would provide bonus payments and higher fee schedule updates for practices that are designated as qualifying APM participants. Patient Centered Medical Homes and other types of alternative payment models have the potential to see higher payments starting in 2017.

During 2015 ACP succeeded in getting several important changes to the Medicare EHR Incentive Program (Meaningful Use), including making the 2015 reporting for Stage 2 easier and also making it easier for physicians to get hardship exceptions. In addition, CMS Acting Administrator Andy Slavitt agreed that the entire Meaningful Use program needs to be redone.

Why it matters to ACP members

Starting in 2017 physicians will be subject to potential Medicare payment penalties based off of their 2015 Meaningful Use performance. Without the changes to the program now, many more physicians would have been seeing payment cuts.

How did ACP help you?

ACP had spent the year telling CMS that there were problems with Stage 2 of the meaningful use program and that most physicians would be unable to meet the requirements they laid out. As a result in October CMS published a rule that would only have physicians attest to meeting meaningful use requirements for a 90 day period in order to meet the requirements of the program, instead of for the full calendar year of 2015. However, by the time the rule was published on October 16, fewer than 90 days remained in year, leaving them insufficient time to comply. ACP began pushing for changes that would make it easier for physicians to be granted a hardship exemption, since many would still be unable to comply with the program. Now, under the new law CMS has extended the deadline for physicians to apply for an exemption until July 1, 2016. Also under the new law, CMS will be able to approve exemptions for categories of physicians instead of needing to review each application on a case-by-case basis, making them easier to grant.

Additionally, thanks to ACP’s efforts, changes were made to the Objective for Patient Electronic Access and the Objective for Secure Electronic Messaging for Stage 2, making the objectives easier to meet.

Looking forward to Stage 3, ACP was the first to call for a halt to the implementation of Stage 3 of the program, allowing time for a complete revamp. In December we provided CMS with extensive comments outlining the drastic changes that are needed. Thanks to agreement from Acting Administrator Slavitt that the existing program needs to be replaced as we move forward with MACRA, we are hopeful that CMS will take into account the changes we call for.

In December ACP provided CMS with extensive comments on how we believe Stage 3 needs to be changed. We are hopeful that CMS will realize that drastic changes are needed to the program so that it better transitions into the changes to reporting programs that will result from the implementation of MACRA. We are continuing to work on behalf of members and other internists to ensure that CMS understands the drastic degree of changes that still need to be made to this program.

As of January 1, 2017, most services provided by an off-site hospital department that was not billing as a hospital prior to fall 2015 will not be eligible to add an additional facility fee to their claims.

Why it matters to ACP members

The financial incentives presented by the facility led to hospital systems purchasing independent physician practices and designating them as an outpatient department of the hospital. In many cases the combined provider and facility fee led to an increased bill for patients, while decreasing payments to physicians.

How did ACP help you?

Early in 2015 ACP told Congress that in keeping with the principles of our high value care initiative, ACP supports delivery of care in the most efficient setting, while maintaining quality of care. The potential savings that could be realized through adjustments to make payments equal across health care settings could be substantial. ACP believes that site- neutral payments would reduce healthcare spending, eliminate unfair incentives for consolidation and protect patient access to healthcare in the community setting.

The upcoming changes are thanks to a provision of the Bipartisan Budget Act of 2015. While not eliminating the problem completely, and making Medicare payments for physicians completely site-neutral, this is an important step in recognizing the problem.

In 2015 several coding changes were made that will mean increased reimbursements to internists, these include chronic care management codes, new advanced care planning codes, and changes to the transitional care management code.

Why it matters to ACP members

These new codes mean that internists and other physicians will begin to be paid for some of the work physicians perform on behalf of their patients outside of traditional office visits.

How did ACP help you?

In 2015 CMS began paying for a chronic care management code for services provided to Medicare beneficiaries who have multiple, significant chronic conditions. In addition to office visits and other face-to-face encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). ACP advocated for the code to be established, and continues to advocate for improvements in the, now, existing code. These changes include asking for the elimination of the beneficiary copayment for these services.

ACP has long advocated for better reimbursement for advance care planning, and earlier in 2015 had sent a letter to CMS advocating to have these codes included in the fee schedule. As part of the 2016 Medicare Physician Fee Schedule CMS began paying for Advanced Care Planning Codes as of January 1, 2016. The new codes will provide payment for discussions that include addressing the patient’s current disease state, disease progression, available treatments, cardiopulmonary resuscitation, life sustaining measures, life expectancy considering the patient’s age and co-morbidities, and clinical recommendations of the treating physician, as well as reviews of patient past medical history, medical documentation/reports, and response(s) to previous treatments. The codes can be billed along with other office visit codes and provide an estimated payment of $75 or $85 for the discussion, depending on whether it is the initial discussion or a follow-up.

Also for 2016, a critical change was made to the transitional care management code to cut down on the administrative burdens of the code. In 2013 Medicare began paying this code that is meant to cover the non-face-to-face services a physician provides after a patient is discharged from the hospital. However, prior to the recent changes, physicians were forced to wait until the end of a 30 day period in order to bill for these services, resulting in a delay in payment. Now they are allowed to submit their claim on the day that the initial face-to-face visit occurs. This change aligns the code better with the typical billing workflow in a physician office, making it easier to submit.

Despite attempts by the House of Representatives to terminate AHRQ in 2016, the agency survived and will continue to operate thanks to funding received in the final Fiscal Year 2016 Omnibus Appropriations bill that was enacted at the end of 2015.

Why it matters to ACP members

AHRQ is the leading public health service agency focused on health care quality. Their mission is “to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work . . . to make sure that the evidence is understood and used.”

How did ACP help you?

A proposed version of the Omnibus bill would have totally eliminated any funding for AHRQ. Additionally, the bill would have prohibited AHRQ-related research at other federal agencies with very rare exceptions.

ACP advocated to members of the House Appropriations Committee that the provisions in the Omnibus bill needed to be eliminated and AHRQ preserved. We told them that we strong believe that AHRQ’s activities and related outcomes research provide incomparable and invaluable data that cannot be replicated or replaced elsewhere in the federal government or the private sector. While the most recent threat has been averted, ACP will continue to advocate for AHRQ and the continuation of the important work they perform.

Mandatory funding for the National Health Service Corps (NHSC) was extended for fiscal years 2016 and 2017.

Why it matters to ACP members

Funding for the Corps had been set to expire on October 1, 2015. NHSC is vital to providing primary health care to underserved communities and training a new generation of primary care physicians. Thousands of ACP members, currently and over many decades, have received scholarships or loan forgiveness through the NHSC, making the program one of the most vital sources of funding for Graduate Medical Education.

How did ACP help you?

ACP told Congress that the NHSC needed to continue its work to help expand the country’s primary care workforce and meet the health care needs of medically underserved communities across the country. The College noted that with increased funds the program could support the training of many more primary care physicians who commit to meeting the healthcare needs of millions of underserved patients, while alleviating the debt burden on them.

The two-year funding extension was included in the MACRA law in the spring, but ACP continues to advocate on behalf of NHSC. In December ACP told Congress that while the mandatory funding has been secured for the next two years, that the Corps needed additional discretionary funds to continue and expand its mission.

In June the Supreme Court of the United States issued their ruling that the insurance premium subsidies that are part of the Affordable Care Act will continue to be available in states where the federal government manages their health insurance marketplace.

Why it matters to ACP members

ACP has a long history of supporting efforts to extend health insurance coverage to all. We believed that eliminating the subsidies to purchase insurance in states with federally-run exchanges would have led many to drop coverage or elect to go uninsured, not only endangering their own health, but driving up the health insurance premiums for those who did remain covered.

How did ACP help you?

In January 2015 ACP joined with other physicians, nurses and community health centers on an amicus brief that was submitted to court to urge them to uphold the subsidies because of the grave consequences a ruling against them could pose for the health and well-being of all Americans. The case before the court argued that the specific language included in the final law only made those in states with state-operated exchanges eligible for the subsidies described in the law. The petitioners argued that the regulations implementing the law had been written to incorrectly also include subsidies for people in states where exchanges were federally run. The Supreme Court’s ruling, by rejecting these arguments, upholding the subsidies, and echoing the concerns ACP raised about the adverse impact of overturning the subsides, likely prevented millions of Americans from losing their health insurance.