Health Policy Advisor’s New FormatAMDA’s Policy Newsletter the Health Policy Advisor has changed its format! In order to provide AMDA members with more timely information, the former quarterly newsletter will now have weekly news items included in AMDA’s Weekly Round Up e-mails. These news items also will be posted on AMDA’s Health Policy Advisor website. So be sure to check out AMDA Weekly Round for the latest in AMDA’s policy news! May 2008 The Centers for Medicare and Medicaid Services (CMS) has released the 2008 Action Plan for (Further Improvement of) Nursing Home Quality. The annual plan summarizes the agency's five inter-related and coordinated approaches on Consumer Awareness and Assistance; Survey, Standards, and Enforcement Processes; Quality Improvement; Quality through Partnerships; and Value-Based Purchasing. The 2008 plan provides CMS' milestones for the year including participation in the Advancing Excellence Campaign; the posting of Special Focus Facilities that have failed to improve significantly on the Nursing Home Compare website; further implementation of the Quality Indicator Survey; and a call to nursing homes for participation in a demonstration program in which payment is adjusted in a manner to recognize improvements in nursing home quality. Looking forward, CMS states that it will complete the following actions in 2008:
To view the 2008 Action Plan for (Further Improvement of) Nursing Home Quality, go to http://www.cms.hhs.gov/CertificationandComplianc/Downloads/2008NHActionPlan.pdf. AMA/RUC Issues Recommendations on Medicare Medical Home Demo Recommendations on the new Medicare medical home demonstration project were submitted to the Centers for Medicare and Medicaid Services (CMS) by the American Medical Association/Specialty Society Relative Value Scale Update Committee, commonly known as the RUC. The RUC recommendations are specific to the development of the reporting mechanism and underlying data that CMS will use to determine payments in the medical home demonstration project. These data include physician work relative value (RVU) and practice expense input recommendations, such as electronic medical record costs and nurse care coordination. “The RUC has demonstrated its support for the medical home demonstration project, and the primary care physicians caring for our nation's aging population by unanimously approving the recommendations to CMS,” said RUC Chair William Rich, MD. “The support of the full RUC is a testament to the willingness of physicians from all specialties to support the evolution of primary care, and to help primary care physicians provide comprehensive and coordinated patient centered medical care.” The three-year demonstration project will begin on January 1, 2009 in rural, urban, and underserved areas in up to eight states, and was mandated by Congress through the Tax Relief and Health Care Act of 2006 (TRHCA). The medical home is described as a large or small medical practice where a physician provides comprehensive and coordinated patient centered medical care. The legislation specifically requested that CMS use the RUC process to develop a case management fee and valuation, and it is the first time that CMS has been congressionally mandated to seek the RUC's advice in valuing a Medicare demonstration project. The RUC assisted in the development of HCPCS G Code descriptors for three tiers of medical homes. A Tier 3 home is the most sophisticated level of home, providing the greatest level of care management services and utilizes an electronic medical records system. A Tier 2 home is considered the typical home and provides a high level of patient care management. A Tier 1 home is the least sophisticated (entry level) medical home and was developed to create an opportunity for even the smallest physician practices to participate in the demonstration project. The RUC estimates that the typical medical home will provide coordinated care services to 250 eligible participating Medicare beneficiaries. This estimation is based on statements from CMS that indicate that 86% of all Medicare beneficiaries will qualify for participation within the typical physician practice. AMDA's Public Policy Committee has formed a medical home work group that is charged with providing AMDA members with information on the model's impact on long-term care physicians. AMDA also has joined the Patient Centered Primary Care Collaborative to strengthen its communication ties with original supporters of the model, including the American Academy of Family Physicians, and the American College of Physicians. “While this model doesn't affect nursing home reimbursement, it has a significant impact on frail patients that many of us treat in other sites, including assisted living. It's ability to provide value-based care, and how it will interact with skilled care, will be monitored carefully,” said AMDA President Chuck Crecelius, MD, PhD, CMD. To view a copy of the RUC's recommendations please visit: http://www.ama-assn.org/ama/pub/category/18528.html Due to overwhelming interest, the Institute of Medicine (IOM) has decided to release the PDF version of the entire prepublication of the report “Retooling for an Aging America: Building the Health Care Workforce”. It is now available for FREE download on the National Academies Press (NAP) website. You can get there through our website at www.iom.edu/agingamerica or at the NAP website at www.nap.edu. CMS Proposes 3.3% Cut for SNF PPS for FY 2009 On May 1, 2008, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule for the Prospective Payment System (PPS) and Consolidated Billing for Skilled Nursing Facilities (SNFs) for FY 2009, which includes a decrease of 3.3% or $770 million for SNFs. If finalized, the cut would be somewhat offset by the 3.1 percent market based update for FY 2009, netting a 0.3 percent cut, or $60 million for FY 2009. In a press release issued subsequent to the proposed rule, CMS says that the updates “more closely reflect the differences in patient care needs”. In April, the Medicare Payment Advisory Commission's (MedPAC) recommendation was that the Congress should eliminate the update to payment rates for SNF services in fiscal year 2009. The American Health Care Association (AHCA) opposes the proposed cuts. The association estimates that the cuts will have the net effect of cutting SNF payments by approximately $5 billion over the next five years. In a press release issued on May 1, 2008, the AHCA warned that such cuts could negatively impact SNF ability to care for an increasing higher acuity patients. All stakeholder comments on the proposed rule are due June 30, 2008. The proposed rule is available at http://edocket.access.gpo.gov/2008/pdf/08-1214.pdf. To view the CMS press release and more information on the proposed rule please click here. April 2008 President Signs Falls Prevention Bill On April 23, 2008, the Safety of Senior Act (S.845) was signed into law by President Bush. Critical New Information
Added to Nursing Home Compare Web site Medicaid beneficiaries and families searching for top quality long-term care services can find critical new information added today to the Centers for Medicare & Medicaid Services’ (CMS) Web site “Nursing Home Compare.” For the first time, information about nursing homes on the Compare Web site will list whether a home is or has been on CMS’ special focus facility (SFF) list. The agency’s SFF initiative gives heightened scrutiny to nursing homes that have a history of poor performance or repeated violations of state and federal health and safety rules. “Today’s expansion of information on Nursing Home Compare will give beneficiaries a more complete picture of a nursing home’s history of providing quality care,” CMS Acting Administrator Kerry Weems said. The SFF initiative was created because a number of facilities were consistently providing poor quality of care, yet were periodically instituting enough improvement that they would pass one survey only to fail the next (for many of the same problems as before). Such facilities with a “yo-yo” compliance history rarely addressed underlying systemic problems that were giving rise to repeated cycles of serious deficiencies. In November 2007, the agency began publishing a list of Medicare and Medicaid participating nursing homes that have a history of serious quality of care problems and had failed to show significant improvement. In February 2008, CMS took the next step and published an updated, expanded list of nursing homes in the SFF initiative and included the category they fell within such as new additions, not improved, improving, recently graduated or no longer in the Medicare and Medicaid programs. As of April 2008, there are 134 SFFs, out of about 16,000 active nursing homes. CMS works closely with states to select participants and as homes improve their quality of care and “graduate” from the program, or fail to improve and are terminated from Medicare and Medicaid, new homes are added to the list. This movement of homes off the list allows more facilities with problems to be added as the program continues. Once a facility is selected as an SFF, the state survey agency conducts twice the number of standard surveys and will apply progressive enforcement until the nursing home either (a) significantly improves and graduates from the SFF initiative, (b) is granted additional time due to promising developments, or (c) is terminated from Medicare and/or Medicaid. CMS and the state can more quickly terminate a facility that is placing residents in immediate jeopardy.
Nursing homes that have the SFF designation, including information about that designation, will now be noted on Nursing Home Compare, which can be accessed at www.medicare.gov. The site helps families find nursing homes in their area. Information about the homes includes performance scores on quality measures, staffing information and a three-year history of the home’s health, safety and fire inspection reports. The Web site will be updated with new information quarterly. The publication of the SFF list was the first major step in CMS’ latest efforts to improve nursing home care. A comprehensive, multi-year look at future actions the agency will take was also released today. The “2008 Action Plan for Further Improvement of Nursing Home Quality” consists of several inter-related and coordinated approaches:
A copy of the full 2008 nursing home action plan can be found at: http://www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp#TopOfPage.
CMS is taking the first step in trying to improve the transparency of nursing homes across the country. A more extensive plan has been introduced by Senators Charles Grassley (R-IA) and Herb Kohl (D-WI) and Representaive Eddie Bernice Johnson (D-TX) entitled The Nursing Home Transparency and Improvement Act of 2008. The bill would improve transparency by providing consumers with better access to standardized, accurate information on how good the care is in nursing homes, including the results of government inspections, the number of direct care staff employed at a home, and information about a facility’s ownership. The bill also aims to strengthen the government’s system of enforcement for homes that are found to have serious quality problems. AMDA currently is reviewing the legislation. A fact sheet can be found by visiting this website: http://www.amda.com/advocacy/legal/factsheet_110.cfm CMS Offers Alternative PQRI Reporting Methods AMDA Health Policy Analyst Alex Bardakh, attended the April 17th meeting with Michael Rapp, MD, JD, FACEP, Director, Quality Measurement & Health Assessment Group at the Centers for Medicare and Medicaid Services (CMS) regarding the memorandum. Dr. Rapp reviewed and answered questions about the new time frames and registry-based reporting methods for participating in the 2008 PQRI. Alternative Time Period for Claims-Based Reporting
Registry-Based Reporting Providers who choose to use registry-based reporting must report on at least three measures (as opposed to one-to-three in the claims-based method). Unlike claims-based reporting, providers can choose to report from July 1, 2008–December 31, 2008. However, there is no real advantage to doing that if registries have the capability to track patients back to January 1, 2008. Payment for 2007 PQRI CMS Updates Claims Processing Manual To view the CMS notice and the related MedLearn Matters article please click here In addition, CMS updated the Medicare Claims Processing Manual, Chapter 12, §§30.6.15.1 and 30.6.15.12 that allows the use of prolonged service codes (99354-99355) for outpatient settings, 99356-99357(new code) for inpatient settings in conjunction with other evaluation and management (E/M) codes. The effective date of this change request is July 1, 2008. In a conversation with CMS, they suggest following the guidelines for prolonged service codes found in the American Medical Association’s CPT 2008 book (See pages 26-27.): “Either code [99354 or 99356] may be used to report a total duration of prolonged service of 30-60 minutes on a given date. Either code should be used only once per date, even if the time spent by the physician is not continuous on that date”. In addition, code 99355 or 99357 “is used to report each additional 30 minutes beyond the first hour, depending on the place of service. Either code may also be used to report the final 15-30 minutes of prolonged service on a given date. Prolonged service of less than 15 minutes beyond the first hour or less than 15 minutes beyond the final 30 minutes is not reported separately”. Click here to see the table of threshold times required to use these codes. Change Request 5972 is available at http://www.cms.hhs.gov/transmittals/downloads/R1490CP.pdf.
CMS Issues Final Rule The Centers for Medicare & Medicaid Services (CMS) issued the final regulation that could allow nearly one million Medicare beneficiaries with limited income and resources to remain in their current Medicare prescription drug plan without having to pay a premium. Part D Legislation Introduced in March 2008, by Representative Lloyd Doggett’s (D-TX), the Medicare Part D Home and Community Services Copayment Equity Act of 2008 is a bipartisan measure that aims to correct the oversight in the Medicare Part D program by exempting drug co-payments for dually eligible residents in assisted living and other home and community-based care settings. Before implementation of Part D, assisted living residents who received Medicaid and Medicaire benefits were exempted from co-payments. To read AMDA’s fact sheet on the Medicare Part D Home and Community Services Copayment Equity Act visit: Falls Prevention Bill Awaits Presidential Approval On April 14, 2008, the Safety of Seniors Act (S.845), that was passed by Congress in August 2007, was presented to the President for his signature. AMDA applauds Congress for passing legislation on this important issue. “Falls are a significant cause of injury in the frail elderly. Nursing facility patients fall for various reasons and there are many factors that contribute to a greater risk for falls, “ said Jaqueline Vance, AMDA Director of Clinical Affairs. She goes onto say that “this bill takes great steps towards reducing the risk of unnessary injuries and is in stride with AMDA’s Clinical Practice Guideline on Falls and Fall Risk”. This legislation encourages public and professional education strategies to raise awareness about elder falls, research to identify at-risk populations, and includes demonstration projects aimed at preventing falls among older Americans. The Falls Free Coalition, led by the National Council on Aging, and many other organizations including the National Safety Council, AARP, the American Occupational Therapy Association, worked with Senators Michael Enzi (D-WY) and Barbara Mikulski (D-MD) and Representatives Frank Pallone (D-NJ) and Ralph Hall (R-TX) to pass the legislation.
AMDA Joins Patient Centered Primary Care Collaborative AMDA has joined the Patient Centered Primary Care Collaborative. The Collaborative is a coalition of organizations representing primary care physicians and other stakeholders who have joined to advance the patient centered medical home (PCMH). The Collaborative believes that, if implemented, the patient centered medical home will improve the health of patients and the health care delivery system. AMDA attended the Collaborative’s April 16th stakeholder meeting where the coalition will discuss topics including implementing the patient centered medical home and integrating it into health reforms. To view the Joint Principles of the Patient Centered Medical Home, which AMDA Board of Directors’ voted to support in December 2007, visit the Collaborative’s website at http://www.pcpcc.net/content/joint-principles-patient-centered-medical-home. MedPAC Recommendations Seek to Promote Primary Care and Change SNF PPS The Medicare Payment Advisory Commission (MedPAC) will recommend a set of initiatives to reward and promote primary care and change the skilled nursing facility (SNF) prospective payment system (PPS). MedPAC members discussed the draft recommendations during a meeting on April 9, 2008 that was attended by AMDA Director of Government Affairs, Kathleen M. Wilson, PhD. MedPAC has recommended two initiatives to promote the use of primary care in Medicare. The first initiative would provide a budget neutral payment adjustment for primary care services billed under the physician fee schedule and furnished by primary-care focused practitioners. The second recommendation is that Congress should initiate a medical home pilot project in Medicare. In addition, MedPAC recommended that the pilot should require a physician pay for performance program. About 10 years after CMS implemented the skilled nursing facility (SNF) prospective payment system (PPS), MedPAC also has recommended that Congress should require the Secretary of Health and Human Services to revise the SNF PPS by adding a separate non-therapy ancillary component. That component includes intravenous medications, respiratory care, and drugs. The commission also recommended that the therapy component be replaced with one that establishes payments based on predicted care needs. The commission will include finalized recommendations in its report to Congress in June. Look for in-depth coverage of the MedPAC recommendations in June’s Caring for the Ages. IOM Report Calls for Geriatric Training for the Health Care Workforce
Dr. Rowe said several facts contributed to the need for these recommendations. First, by 2030, the number of people over the 65 will have doubled since 2005. Second, the workforce is ill prepared to address multiple medical problems of the older adult population. In particular, specialists are unprepared to handle the most complex patients. Last, coordination among providers is lacking. Workforce Competency Care Delivery
For more information on the report, visit www.iom.edu/agingamerica. The Senate Special Committee on Aging is drafting legislation to implement some of the report’s recommendations. AMDA currently is reviewing the legislative framework. AMDA Public Policy Committee’s Work Group on the Long Term Care Work Force will be reviewing the report’s recommendations. The work group members, Leonard Gelman, MD, CMD; Daniel Haimowitz, MD, FACP, CMD; Paul Katz, MD, CMD; Karyn Leible, MD, CMD (chair of Public Policy Committee); and Paul Mulhausen, MD, MHS; will be reviewing the recommendations in light of current and future AMDA policy.
AMDA Attends a Long Term Care Discussion Group Meeting That Proposes LTC Financing Reform On March 27, 2008, AMDA staff attended a meeting held in Washington D.C, to discuss long-term care (LTC) financing reform.The American Health Care Association (AHCA) has partnered with the National Center for Assisted Living (NCAL) and the Alliance for Quality Nursing Home Care to create a proposal for (LTC) financing reform. Their proposal calls for a new payment system for post-acute care with a uniform assessment system, conversion of Medicaid LTC to a federal program, emphasis on personal responsibility to plan for LTC costs, incentives and new ways to save for LTC expenses, and a major national educational program. The proposal provides a timeline of ten years to implement this program. This proposal is among the various proposals that aim to shift LTC coverage away from the Medicare/Medicaid payment system to a private pay system with personal responsibility. Combined, Medicare and Medicaid pay nearly 70% of the nation’s post-acute LTC costs. According to the American Health Insurance Plans’ (AHIP) Center for Policy and Research, only 10% of the population age 55 and over have private LTC coverage. Most of today’s elderly require more than one year of stay at long-term care facilities, however Medicare does not cover those extended stays. Medicaid is unable to cover individuals’ LTC expenses since many states are running out of funds and LTC already encompasses more than 35% of most state budgets. Congress has recognized this problem as well. More than 50 associations have signed on to the recently proposed Community Living Assistance Services and Supports (CLASS) Act of 2007. The act creates a savings program where individual would contribute $30 in monthly premiums for at least five years to receive benefits. AMDA is reviewing and monitoring this legislation. Both the CLASS Act and this proposal address issues of patient access to quality care and do not yet focus on the issue of physician reimbursement for services. If, however, these programs are able to provide for more cost effective care, it could mean that more money is available for reimbursement of services. New Payment System for Post-Acute Care Personal Responsibility and Federal Benefit In order to be eligible for these benefits, individuals must first meet their share of financial responsibility. The proposal suggests that— on average— the personal responsibility would be about $100,000, however it will be based on a sliding scale. Payment could range anywhere between no personal responsibility for low-income individuals to about $150,000 for higher-income individuals. Once the personal benefit has been met, the federal benefit would apply. A limited benefit would be available for those individuals who do not meet the personal responsibility requirement. For those individuals that do meet the requirement, they will have three ways to receive the benefit: 1) cash benefits; 2) payment directly from a nursing facility or assisted living facility, which will submit claims for delivered services to the administrative contractors; 3) enrollment in a Medicare Advantage (MA) plan that provides the LTC benefit and arranges for services. LTC benefits will be administered by administrative contractors or by MA plans, much like the Medicare benefits that are administered today. Saving for and Enrolling in the Benefit AMDA will continue to monitor the developments of this and other proposals. Please check the Health Policy Advisor web page http://www.amda.com/publications/healthpolicyadvisor.cfm for future updates. Help stop the July 1, 2008 10.6% Physician Pay Cut! On March 13, 2008, Senator Debbie Stanebow (D-MI) introduced the Save Medicare Act of 2008 (S. 2785). This legislation proposes to replace the 10.6% cut in 2008 and continue the 0.5% positive update through December 31, 2008. Likewise, the legislation proposes to replace the 5% cut scheduled for 2009 with a 1.8% positive update. In addition, the legislation would continue funding for the Physician Quality Reporting Initiative (PQRI) through 2010. PQRI currently pays physicians a 1.5% bonus payment on all eligible expenses for successfully reporting relevant quality measures. The American Medical Association (AMA) applauds and fully supports the bill. “New legislation introduced by Senator Stanebow is the critical ingredient needed to save seniors’ access to care as it stops this year’s harsh Medicare payment cut to physicians,” said AMA President-Elect Nancy Nielsen, MD, PhD, in a March 14, 2008 statement. Now we need your help! Please help support this bill by contacting your local legislators and tell them of your support. Simply visit http://capwiz.com/ama/home to contact your local legislators now!While, Senator Stanebow’s legislation is just a temporary fix, a separate bill has been introduced to provide a more permanent solution to the problems with physician reimbursement. On March 6, 2008, Senator John Cornyn (R-TX) and Representative Michael Burgess, MD (R-TX) introduced the Ensuring the Future Physician Workforce Act of 2008, S. 2729 and H.R. 5545 respectively. This legislation would repeal the sustainable growth rate formula (SGR) beginning in 2010, and replace it with the Medicare Economic Index (MEI). Many specialty societies, most notably the AMA and AMDA, have strongly supported the repeal of the SGR. Likewise, this bill would increase the bonus payment for the PQRI program from 1.5% to 3%. Both of these bills are in their respective committees. AMDA will continue to track these bills and provide updates in its Weekly Roundup and Health Policy Advisor http://www.amda.com/publications/healthpolicyadvisor.cfm. As the battle to avoid physician pay cuts continues, Congress is working to approve the federal budget. On March 13, 2008, the Senate approved a budget resolution that did not include President Bush’s proposal to cut $182 billion from Medicare and Medicaid programs. Among the amendments passed in the Senate bill is Senate Amendment 4197 proposed by Senator Herb Kohl (D-WI) and supported by AMDA that establishes a deficit-neutral reserve fund for a 3-year extension of the pilot programs for national and state background checks on direct patient access employees of long-term care facilities or providers. The budget still has to be passed by the House and signed by the President. Tamper-Resistant Prescription Pads Requirement Begins April 1st On Saturday, September 29, 2007, President Bush signed the TMA, Abstinence Education, and QI Programs Extension Act of 2007 delaying the implementation date for all paper Medicaid prescriptions to be written on tamper-resistant paper. Under the new law, as of April 1, 2008, all written Medicaid prescriptions must be on tamper-resistant prescription pads. CMS’ guidance on the tamper-resistant law, set forth in an August 17, 2007 State Medicaid Director letter, contains two phases. For the first, a prescription must contain at least one of the three tamper-resistant characteristics in order to be considered “tamper resistant.” For the second, prescriptions must contain all three characteristics. The two-phased approach will still be in effect. At least one of the three tamper-resistant characteristics is required on April 1, 2008. All three characteristics are required on October 1, 2008. All other guidance that CMS has issued on this requirement contained in the
State Medicaid Director letter and Frequently Asked Questions will still apply once it is implemented. Joint Resolution in Congress for National Health Care Decisions Day On March 12, 2008 a Bipartisan, Joint Resolution was filed by Senators Ron Wyden (D-OR) and Mike Enzi (R-WY) and Representative Phil Gingrey (R-GA) for National Healthcare Decisions Day (NHDD). The Resolution expressed Congressional support for the goals and ideals of the National event which is designed to to raise public awareness of the need to plan ahead for health care decisions related to end-of life and medical deicison making whenever patients are unable to speak for themselves and to encourage the specific use of advance directives to communicate these important decisions. As a part of the NHDD initiative they are conducting a national survey to assess public knowledge and attitudes about advance care planning. The survey questions are based on previous surveys of advance care planning and end-of-life issues. The goal of this survey is to gain a more current assessment of the issues surrounding advance care planning issues. The survey can be completed in five minutes or less by visiting www.nationalhealthcaredecisionsday.org/survey. The deadline for completion is March 24, 2008. AMDA is proud to be involved in NHDD innagural event which will take place on April 16, 2008. Four NF Services Codes Top Part B News List of Codes that Pay More Four of the Nursing Facility Services codes were listed among the ten common physician services codes that are paying more in 2008, according to the March 3rd Part B News, a newsletter that specializes in Medicare news and billing guidance. According to the newsletter’s analysis of the Physician Fee Schedule, the three initial visit codes 99306, 99305, 99304, and the 99307 for subsequent care will pay more in 2007 than in 2008. AMDA had successfully achieved higher physician work values for these codes last year. Please click here to read more Tamper Resistant Prescriptions The Centers for Medicare and Medicaid Services (CMS) have issued two clarifications regarding the requirements for Medicaid tamper-resistant prescriptions that take effect April 1, 2008. 1. Provider Additions to Otherwise Non-Tamper-Resistant Paper CMS has received inquiries from several states regarding whether a provider can add a feature (e.g., embossed logos, writing out the quantities in words rather than numbers, etc.) to a prescription to make it compliant with the requirements. CMS notes that “The statute states that all written prescriptions must be “executed on a tamper-resistant pad.” As a result, features added to the prescription after they are printed do not meet the requirement. By contrast, features that would make the prescription tamper-resistant include certain types of paper as well as certain items that can be pre-printed on the paper. The National Council for Prescription Drug Programs (NCPDP) is sponsoring a focus group to identify best practices and recommend a standard approach to this requirement. Participants include representatives from provider groups and pharmacy groups, as well as vendors and state Medicaid directors. 2. Computer Generated Prescriptions CMS has also clarified that from April 1, 2008 to October 1, 2008, computer generated prescriptions printed by a provider on plain paper, including Electronic Medical Record (EMR) computer generated prescriptions, may meet CMS guidance by containing one or more industry-recognized features designed either to prevent the erasure or modification of information contained on the prescription, or to prevent the use of counterfeit prescription forms. Beginning October 1, however, prescriptions must be written on paper that meets three baseline characteristics identified by CMS. CMS does not believe that computer generated prescriptions printed by a prescriber on plain paper will be able to meet all three baseline characteristics. As a result, computer generated prescriptions written after October 1 must be printed on paper that meets that requirement. Examples of industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form which include, but are not limited to: watermarks, micro-printing, and paper on which the word “void” appears when copied.” CMS has specified that the tamper-resistant prescription requirement does not apply in nursing facilities, but it will apply for outpatient prescriptions. In earlier guidance, CMS deemed that states that already had mandatory tamper-resistant programs in place meet the requirements of the law. The requirement was originally to take effect October 1, 2007, but provider groups, including AMDA, requested more time for implementation, and the implementation date to meet one of CMS’ standards was delayed until April 1, 2008. Date for full implementation is October 1, 2008. Further information on this guidance is to be available at www.cms.hhs.gov/DeficitReductionAct/30_GovtInfo.asp. Medicare Drug Benefit Part D Update – 2008 The new year is the beginning of another new year for the Medicare Part D drug program. Contrary to predictions, the number of drug plans is still robust, and despite often significant premium increases, the majority of enrollees are not changing plans to seek lower cost alternatives. Here is a look at some details of Part D for 2008: Drug Plans—1,824 free-standing drug plans (PDPs) will be offered in 34 PDP regions (about the same number as in 2007). Beneficiaries in most states have a choice of at least 50 PDPs and multiple MA-PD plans. There are 17 plans operating nationwide (in all 50 states and the District of Columbia). Benefits and Premiums— For 2008, the majority of PDPs (59%) have no deductible, and most charge tiered co-payments rather than the standard 25% coinsurance. The monthly premium is expected to average about $31.99, which represents a 17% increase over 2007, according to the Kaiser Family Foundation. CMS had projected average cost at $25/month. According to CMS, the premiums are 40% lower than were originally projected in 2003. CMS credits slower than expected growth in drug costs, and particularly the impact of increased use of generic drugs, as one reason for lower costs, together with effective price negotiation and strong competition. Actual premiums vary greatly from state to state, and depending on extent of coverage. According to Consumers Union, 75 percent of Medicare drug plans have raised their costs in 2008, averaging $369 for the five commonly used drugs between December 2007 and January 2008. The “doughnut hole” in which there is no Part D coverage begins when total drug costs (those of the enrollee and the government) reach $2,510, and continues until enrollees have accrued $4,500 in out of pocket expenses (excluding the Part D premiums). Most PDPs (71%) do not offer any coverage in the coverage gap, but among those that do, all but one cover only generic drugs. PDPs with gap coverage are approximately twice as expensive as those without the coverage. Just over 3 million beneficiaries were projected to have spending in the coverage gap in 2007, according to a Kaiser Family Foundation study. Cost sharing “tiers” allow PDPs to promote an incentive for enrollees to Of 13.2 million beneficiaries eligible for low-income Part D assistance, an estimated 3.3 million were not receiving it. To encourage enrollment of low-income beneficiaries, CMS has proposed a rule to allow prescription drug plans, under certain conditions, to offer a reduced premium amounts for certain individuals eligible for Medicare's low-income subsidies. According to CMS, more than 90% of PDP enrollees did not switch plans between 2006 and 2007. If that trend continues for 2008, 75% of enrollees will face premiums increases. Formularies — CMS has dropped the requirement that plans have one medication from every key drug type on the USP Model Guidelines. They plan to use an “outlier test” approach to make sure the formulary is reasonable, comparing formularies from various plans with one another. Avalere Health says that Medicare Part D plans are reducing the number of drugs they cover for 2008, with an average of 26% decrease in drugs covered. But that may not be all bad news. Part of that decrease is based on FDA assessments of efficacy. There have been many drugs on the market that were approved by FDA between 1938 and 1962 based on safety but not on efficacy. The FDA has been trying to determine efficacy on those drugs, and many have been deemed to be “less than effective”, and their approval has been rescinded. CMS has pulled those drugs from its formulary reference file, and most drug plans are not longer covering them. Thus CMS reduced its formulary reference file from 7,100 products in 2007 to about 5,500 for 2008. According to Avalere, Silverscript is the only one of the top 10 most popular PDPs that is dramatically increasing its formulary for 2008. A CMS spokesman says that the Avalere numbers reflect only the FDA elimination of less than effective drugs, and that formularies have actually increased since last year. Expenditures — HHS estimates that Part D spending will total $50 billion in 2007 and $932 billion between 2008 and 2016. Enrollee premiums are established to cover 25.5% of the cost of standard drug coverage. In 2008, plans are expected to receive $440 per enrollee (and $1,909 per low-income enrollee), in addition to additional risk-adjusted payments for high-cost enrollees and reinsurance for costs above the catastrophic threshold. According to CMS, the agency is seeking to recover $4B from Part D drug plans for lower than expected costs in 2006. The recovery is part of a reconciliation process to adjust payments to reflect actual expenses. CMS Issues Clarification to Chapter 6, SNF Inpatient Part A Billing of the Claims Processing Manual On December 14, 2007, the Centers for Medicare and Medicaid Services (CMS) issued a clarification to Chapter 6, skilled nursing facility (SNF) inpatient Part A billing. Change Request 5840 states that it is not requiring for Skilled Nursing Facility (SNF) providers to submit no payment bills for non-skilled beneficiary admissions. No pay bills are only required for beneficiaries that have previously received skilled care and continue to reside in Medicare-certified area of the SNF. Additionally, CMS states that no payment bills may span both Medicare and a provider’s fiscal year end dates; and no payment bills are not required for beneficiaries in current Medicare Advantage (MA) plans that no longer require skilled care still under the plan. To view the full Change Request, please visit: http://www.cms.hhs.gov/transmittals/downloads/R1394CP.pdf President Signs Bill that Stops 10.1% Conversion Factor Cut President Bush signed, S.2499, The Medicare, Medicaid, and SCHIP Extension Act of 2007 on December 29, 2007. The bill contains a Medicare package worth $5.3 billion that eliminates the 10.1% cut to the Medicare physician reimbursement rate scheduled for January 1, 2008 and replaces it with a six-month payment update of 0.5 percent. Once the pay fix expires in June 2008, the originally scheduled 10.1% cut could go into effect for the remainder of the year pending any legislative action. The bill also extends the therapy cap exceptions process for six months, extends the Physician Quality Reporting Initiative (PQRI) otherwise known as Pay for Performance, and revises the Physician Assistance and Quality Initiative (PAQI) fund. The bill also includes the following provisions:
House and Senate vote to stop the 10.1% cut, President expected to sign bill The House and Senate passed S.2499, The Medicare, Medicaid, and SCHIP extension Act of 2007. The bill contains a Medicare package worth $5.3 billion that eliminates the 10.1% cut to the Medicare physician reimbursement rate scheduled for January 1, 2008 and replaces it with a six-month payment update of 0.5 percent. Once the pay fix expires in June 2008, the originally scheduled 10.1% cut could go into effect for the remainder of the year pending any legislative action. The bill also extends the therapy cap exceptions process for six months, extends the Physician Qualiy Reporting Initiative (PQRI) otherwise known as Pay for Performance, and revises the Physician Assistance and Quality Initiative (PAQI) fund. The President is expected to sign the bill within the next few days. The bill also includes:
CMS User Fees Remain In Place For Now User fees remain in place until at least December 21, 2007. The fees are assessed by the Centers for Medicaid and Medicare Services (CMS) for revisit surveys conducted to evaluate the extent to which deficiencies identified during initial certification or recertification surveys have been corrected... more Update from Practicing Physicians Advisory Council (PPAC) On December 3, 2007 AMDA’s Health Policy Analyst Alex Bardakh attended the semi-annual Practicing Physicians Advisory Council meeting. The meeting included an overview of the Physician Fee Schedule Final Rule that was released on November 1, 2007, an overview of Medicare demonstration projects, an update on new Stark law provisions, and an update on the 9th Scope of Work and the Quality Improvement Organization (QIO) program. Additionally, the American Medical Association provided testimony to address issues related to the looming physician pay cut, physician self-referral (Stark law), the Physician Quality Reporting Initiative (PQRI), and the National Provider Identifier (NPI). Please click here to view the full overview. AMDA signs onto the Joint Principles of the Patient Centered Medical Home Model After receiving approval from the AMDA Board of Directors, AMDA joined the American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), and the American Osteopathic Association (AOA), in support of the Joint Principles for the Patient Centered Medical Home Model. The Joint Principles address issues of quality and safety, access, and payment in the Medical Home Model. To view the Joint Principles please click here New Changes to Physician Self-Referral Regulations (Stark Law) New regulations by the Centers for Medicare and Medicaid (CMS) revise current requirements implement prohibitions on physician self-referrals to Designated Health Services (DHS). The first regulation is the third phase of regulations to implement the self-referral law (commonly known as the Stark Law, after its sponsor, Congressman Pete Stark (D-CA). The regulations are likely to be known as “Stark Phase III”. CMS promulgated additional changes in the 2008 Medicare physician fee schedule. CMS Finalizes Increase Physician Work Values for Nursing Facility Services On November 1, 2007, CMS published an advance copy of the Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2008. The regulations finalize the increased physician work values for the nursing facility codes that AMDA achieved earlier this year. Click here to view the complete summary of Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule for Calendar Year 2008. AMDA to take part in National Healthcare Decisions Day AMDA partners with state chapters to offer recommendations on the draft local coverage determination (LCD) covering physician evaluation and management services provided in the home and domiciliary setting . To view the draft Local Coverage Determination, please click here. Health Policy Advisor Archive
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