San Francisco Medical Society Blog

SFMS/CMA Joins Amicus Briefs Challenging Proposition 8 and the Defense of Marriage Act

Thu, 28 Feb 2013 13:08:47 GMT

Today, the SFMS and CMA joined the AMA and dozens of other health care organizations in filing an amicus brief with the US Supreme Court challenging California’s Proposition 8, which denies state recognition of same-sex marriages. Tomorrow, a similar brief will be submitted challenging the Defense of Marriage Act, which denies benefits to same-sex partners of federal employees.

“CMA strongly supports efforts to reduce health care disparities among members of same sex households, including measures to afford such households equal rights and privileges to health care, health insurance and survivor benefits,” said CMA President Paul Phinney, MD. “We also recognize that denying civil marriage contributes to worse health outcomes for gay and lesbian individuals, couples and their families.”

The brief states that the listed Amici—which includes leading associations of psychological, psychiatric, medical and social work professionals— have sought to present an accurate and responsible summary of the current scientific and professional knowledge concerning sexual orientation and families relevant to this case.

These briefs were filed based on policy passed at last year’s House of Delegates:

Date Adopted: 10/15/2012
Status: Adopted

Resolved #1 - That CMA support efforts to reduce health care disparities among members of same-sex households including minor children

Resolved #2 - That CMA support measures providing same-sex households with the same rights and privileges to health care, health insurance, and survivor benefits afforded to opposite-sex households

Resolved #3 - That CMA recognize that denying civil marriage contributes to poorer health outcomes for gay and lesbian individuals, couples and their families.

For a full copy of the Perry brief, please click here.

Organized Medicine Advocate for Delay in Meaningful Use Rules

Wed, 16 Jan 2013 14:51:07 GMT

Leading medical groups have called on the Department of Health and Human Services (HHS) to delay implementation of Stage 3 of meaningful use of electronic health records (EHRs), saying providers are still trying to implement Stages 1 and 2.

"Meaningful use" refers to provisions in the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, which authorized incentive payments through Medicare and Medicaid to clinicians and hospitals that use electronic health records in a meaningful way that significantly improves clinical care.

The American Medical Association, which called for a delay in implementation, said the meaningful use program has helped kick start EHR use but noted there are still technical, financial, regulatory, and operational challenges that must be dealt with first.

The American College of Physicians wrote in its comments that Stage 3 measures don't focus enough on patient outcomes, although that was supposed to be their goal. Instead, HHS' measures are a growing collection of functional metrics.

The Association of American Medical Colleges wrote that Stage 3 requirements should strike a balance between imposing difficult measures without having a negative impact on patient care for those providers who don't meet such measures.

In its comments on proposed Stage 3 requirements issued by HHS, the American Academy of Family Physicians called for a delay in implementation until at least 2017, adding it also wants to delay or eliminate penalties for the third and final stage of the EHR incentive program.

HHS finalized its regulations for Stage 2 in August, requiring that physicians complete that stage by October 1, 2014 or face a 1% penalty from Medicare. That was a 9-month delay from its original deadline.

A finalized Stage 3 rule should be released later this year.

Source: Medpage Today, January 15, 2013.

AMA Update on Medicare Payment Rates

Thu, 03 Jan 2013 11:45:04 GMT

The American Taxpayer Relief Act of 2012 was signed into law January 2, 2013. The new law averts the 26.5% SGR cut for all of 2013 and the 2% sequester for the next two months. It also extends the work GPCI floor for a year. Today CMS released the attached announcement regarding updated 2013 Medicare payment amounts, claims processing, and reopening of the participation enrollment period.

Carriers are not expected to post the new rates on their web sites until at least next week and possibly later.

In the meantime, some practices are asking what they should charge. By law, Medicare is required to pay physicians the lesser of the submitted charge or the Medicare approved amount. For this reason, the SFMS is advising against submitting claims with the reduced 2013 amounts. Instead, we recommend physicians either defer submission of claims for 2013 dates of service until the new 2013 rates are published, or continue charging the 2012 rates.

In addition, due to relative value changes that will affect some 2013 payment amounts and limiting charges, for unassigned claims practices should probably wait to bill patients directly for cost-sharing amounts until the new 2013 rates are published.

Source: American Medical Association

SFMS/CMA Urges Congress to Stop $11 billion in Medicare Sequestration Cuts

Mon, 17 Sep 2012 16:39:52 GMT

Hospitals and other providers will see Medicare payment reductions totaling $11.1 billion next year, due to the Budget Control Act of 2011, unless Congress passes new measures to prevent the cuts, according to a report from the White House’s Office of Management and Budget.

This comes just days after the SFMS/CMA, American Medical Association, and 99 other state and specialty societies submitted a letter to Congress urging the passage of legislation nullifying the 2 percent cut payments called for under the sequestration act.

The 2 percent Medicare “sequestration” cuts are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year’s debt-ceiling crisis. Under the act, across-the-board cuts will be triggered if Congress fails to come to an agreement on how to reduce the federal deficit.

These cuts would come on top of the 27 percent Medicare physician payment cuts triggered by the flawed sustainable growth rate (SGR) formula.

The letter to Congress argues that “the combination of a sequestration cut and looming Medicare sustainable growth rate payment cut would not only impede improvements to our health care system, it could lead to serious access to care issues for Medicare patients as well as employment reductions in medical practices, we strongly urge Congress to work diligently during the fall to reach a bipartisan agreement to pass legislation nullifying the Medicare physician payment cuts.”

SFMS/CMA and the other cosigners also expressed a commitment to work with Congress on the shared goal of delivery and payment reform in the Medicare program. “To reach this goal, adequate and stable investments are necessary so that physicians can modernize their practices to support the coordinated care that will improve health and prevent costly complications and enable the participation in new payment and delivery models,” the letter said.

The sequestration cuts will take effect on January 2, 2013, if Congress fails to either reach a deficit reduction agreement or takes additional legislative action to stop the cuts. Congressional Republicans remain deadlocked with the Obama Administration over sharp differences in their preferred approaches to reduce future deficits.

Coalition Files California Supreme Court Amicus Briefs In Support of Medical Staff Independence and Self-Governance

Thu, 13 Sep 2012 18:25:21 GMT

In a strong show of broad support for medical staff independence and self-governance, 23 current and former chiefs of staff from throughout California have filed an amicus curiae brief with the California Supreme Court in El-Attar v. Hollywood Presbyterian Med. Ctr. SFMS/CMA and AMA have also filed a separate amicus brief in the case. The briefs argue that a hospital’s lay governing board is not qualified to engage in peer review and thus cannot directly or indirectly commandeer a medical staff’s peer review functions.

In this case, the hospital board at Hollywood Presbyterian Medical Center ignored and overrode the medical staff executive committee's (MEC) recommendation to reappoint a physician on staff. When the physician invoked his right to a joint review committee hearing to challenge the hospital’s termination of his privileges, the hospital unilaterally appointed the hearing officer and members of the review committee. Under the medical staff bylaws, however, only the MEC has authority to determine the joint review process, including the appointment of the hearing officer and joint review committee members.

CMA and AMA argued in their amicus brief that the medical staff bylaws here must be strictly enforced in order to uphold the systemic safeguards of a fair and just peer review system. Under California and federal laws, CMA and AMA explained, the professionals on the medical staff have primary responsibility for all of the functions necessary to ensure patient safety and the competence of practitioners at a hospital. These functions, which include peer review, fall within the medical staff’s right to self-governance and independence. Hospital governing bodies have oversight authority, but cannot unnecessarily interfere with the medical staff’s self-governance functions, including peer review.

The California Supreme Court decided to review this case last November. Briefing in the case is complete and a decision can be expected in the latter half of next year.

Don't Gamble with Your Future: Know What's in Your Contract

Thu, 13 Sep 2012 18:04:06 GMT

The American Medical Association (AMA) and the law firm of Kessemick, Gamma & Free are hosting a dinner presentation on evaluating and negotiating contracts. This event is open to all SF residents, fellows, and physicians in their first few years of practice. Enjoy complimentary dinner and drinks while local attorney Frank Gamma JD, MBA, FACMPE shares his 20 years of experience working with physicians.

Wednesday, September 19, 2012
McCormick & Kuletos
The Captain Room
900 N. Point, San Francisco, CA 94109
6:30 pm – Registration
7:00 pm – Dinner and Presentation

To RSVP for this event, please email Patrick O'Keefe at patrick.okeefe@ama-assn.org.

HHS Delays ICD-10 Coding to October 2014

Mon, 27 Aug 2012 12:57:26 GMT

The Department of Health and Human Services (HHS) postponed the use of ICD-10 diagnostic codes until October 1, 2014.

The 1-year delay comes in response to complaints by organized medicine about the administrative burden of converting to ICD-10. SFMS, CMA, AMA, and other medical societies told HHS that converting to the more voluminous and complicated set of diagnostic codes could cost medical practices tens of thousands of dollars and interfere with their migration to electronic health records and electronic prescribing.

ICD-10 stands for the International Statistical Classification of Diseases and Related Health Problems, 10th Revision. The Centers for Medicare and Medicaid Services (CMS) mandated the switch from ICD-9 to ICD-10 as part of implementing the Health Insurance Portability and Accountability Act (HIPAA). HHS considers ICD-9 outdated and imprecise.

ICD-10 contains 68,000 diagnosis codes, which is roughly 5 times the number in ICD-9. The new codes also run to a maximum of 7 characters compared with 5 in the current codes.

HHS also announced establishing a standard format for health plan identifier (HPID) codes that is designed to simplify billing for clinicians and hospitals. Identifiers for health plans now in use differ in format, and that variety invites errors, leading to misrouted transactions, rejected claims, and problems determining patient eligibility, according to HHS. The department estimates that implementing a standard HPID will save the healthcare industry up to $6 billion over the course of 10 years.

Click here for more information on the HHS announcement.

June 2012 AMA Advocacy Update: Senate Approves FDA Safety and Innovation Act, AMA Provides Recommendations for Alternative Payment Models

Mon, 04 Jun 2012 14:58:02 GMT

Excerpts from the June 2012 AMA Advocacy Update. For a pdf copy of the full report, click here. To view the most current national advocacy update, click here.

Senate Approves Food and Drug Administration Safety and Innovation Act
AMA Works to Improve Provisions to Address Rogue Online Pharmacies
AMA Provides Information to Ways and Means Committee on Quality Improvement and Alternative Payment Models

Senate Approves Food and Drug Administration Safety and Innovation Act

On May 24, the Senate passed S 3187, “The Food & Drug Administration Safety and Innovation Act,” by a vote of 96-1. The legislation would reauthorize the Prescription Drug User Fee Act (PDUFA) and the Medical Device User Fee Act (MDUFA), and newly authorize user fees for generic drugs and biosimilars. It also includes provisions to address drug shortages and incentivize the development of new antibiotics. S 3187 was greatly improved from the original draft, and reflects a number of AMA’s requested changes. For example, the AMA urged the Health, Education, Labor and Pensions (HELP) Committee to expand manufacturers’ early notification requirement to report expected shortages for all drugs and to modify provisions relating to new antibiotic development. On May 30, the House passed its version of the user fee reauthorization legislation, HR 5651, by a vote of 387-5. Although the bills are similar minor difference will be worked out in conference committee. The user fees are set to expire on September 30, final Congressional action is expected by June 30.

AMA position: The AMA strongly supports the passage of legislation to address drug shortages and properly incentivize new antibiotic development as a part of the FDA User Fee reauthorization bill. The AMA sent a letter to the HELP Committee commending the improved language and will continue to advocate for its priorities as the bills are reconciled in a House-Senate conference.

AMA Works to Improve Provisions to Address Rogue Online Pharmacies

The AMA has been engaged in reviewing and commenting on several recent drafts of the “Online Pharmacy Safety Act,” originally introduced by Sen. Diane Feinstein (D-Calif.) and Rep. Bill Cassidy, MD (R-La.) as S 2002 and HR 4095, respectively. Rogue online pharmacies represent a serious and growing threat to the health and safety of patients. The legislation as originally introduced would address this by establishing a Food and Drug Administration administered registry to identify legitimate and safe online pharmacies, an approach supported by the AMA.

Several attempts have been made to amend the legislation so that it could be included in the user fee reauthorization legislation. Unfortunately, the registry provisions were removed from subsequent versions of the legislation and the bill was expanded beyond its original intent. Recent drafts of the bill would only retain provisions that would set a federal standard for a valid prescription. This would undermine state valid prescription standards which are also intertwined with other areas of their medical practice codes such as licensure, telehealth and patient safety. The AMA has expressed its concerns over this federal intervention with the proper state regulation of the practice of medicine to the sponsors of the bill and the HELP and Energy and Commerce Committees. The Senate-passed version of the user fee reauthorization legislation (S. 3187) contains a GAO study on rogue online pharmacies. At this writing, the House bill does not include any similar provision.

AMA position: The AMA believes that current versions of this bill constitute an unwarranted and inappropriate federal intrusion into states’ ability to regulate the practice of medicine. The AMA is committed to working with the sponsors to enact laws that will effectively reign in rogue online pharmacies while at the same time protecting the ability of states to regulate the practice of medicine.

AMA Provides Information to Ways and Means Committee on Quality Improvement and Alternative Payment Models

On April 27, 2012, the House Committee on Ways and Means wrote to more than 70 physician organizations requesting information on quality and efficiency improvements, alternative payment models, patient involvement and regulatory relief as part of their efforts to find a long term replacement for the sustainable growth rate (SGR) formula. In response, the AMA has submitted a 26-page letter answering specific questions put forth by the committee. Specifically, the AMA outlined strategies that the physician community could support to both reduce the growth in costs and improve patient outcomes, including a broad rage of payment reform options. AMA also outlined the extensive activities of the Physician Consortium for Performance Improvement and other activities that are already underway, as well as regulatory relief that is needed in order for new payment methodologies to succeed. View the complete letter.

The AMA will continue to work with Congress in their ongoing efforts to find a replacement for the failed SGR formula.

May 2012 AMA Advocacy Update: CMS Releases Final Rule on CoPs, Passage of HR 5652 and Its Effect on Physicians, EHR MU Program

Mon, 21 May 2012 15:19:45 GMT

Excerpts from the May 2012 AMA Advocacy Update. For a pdf copy of the full report, click here. To view the most current national advocacy update, click here.

AMA Protects Physician Hospital Medical Staff
House Passes Reconciliation Legislation
AMA and Others Comment on EHR MU Program
Medicare Now Accepts Physician Enrollment Applications 60 Days in Advance
AMA, Federation staff tackle physician concerns with UnitedHealth Group

AMA Protects Physician Hospital Medical Staff

On October 24, 2011, CMS published a proposed rule to revise the Medicare Conditions of Participation (CoPs) for hospitals that included a number of troubling provisions. AMA strongly advocated to CMS senior staff that the provisions therein would have the effect of severely diluting the authority of hospital medical staffs and could threaten hospital patient safety and health.

As a direct result of AMA advocacy, the final rule—released this month—makes the following improvements:

The proposed concept of a single medical staff for a multi-hospital system has been removed.
The proposed concept of the privileging of physicians without appointment to the medical staff has been removed.
A hospital’s governing body must now include at least one medical staff member.
The proposed concept of credentialing for medical staff membership in accordance with “hospital policies and procedures” has been removed; the final rule defers to state law and “medical staff bylaws, rules, and regulations.”
The mandatory inclusion of non-physician practitioners on medical staffs strongly proposed by several other groups (e.g., American Nurses Association, AARP) was not adopted.

House Passes Reconciliation Legislation

The House passed H.R. 5652, the “Sequester Replacement Reconciliation Act of 2012,” on May 10 by a vote of 218-199. This bill was a combination of the work of six House committees that were required by the FY 2013 Congressional Budget Resolution (H.Con.Res. 112) to produce legislation that would cut the federal deficit by a total of $261 billion over 10 years.

Of interest to physicians, the Judiciary Committee included in its portion of the bill the “Help Efficient, Accessible, Low-cost, Timely Healthcare (HEALTH) Act” (H.R. 5). The HEALTH Act, originally introduced by Rep. Phil Gingrey, MD (R-GA), contains a wide range of AMA-supported medical liability reforms, including a $250,000 cap on non-economic damages. The Ways and Means Committee achieved its required $53 billion savings in part by enhancing provisions to recapture overpayments of health insurance subsidies, which were created under the Affordable Care Act (ACA), and by repealing block grants to states for social services. The Energy and Commerce Committee met its $96.8 billion target in part by including medical liability reform provisions (that differ slightly from the Judiciary Committee approved language). The Energy and Commerce Committee also achieved savings through several changes to the ACA including repealing the prevention and public health fund, defunding the “Consumer Operated and Oriented Plan” (CO-OP) program, repealing the Medicaid maintenance of effort requirement for states, and repealing the direct appropriation for state exchange grant authority.

It is unlikely that the reconciliation measure will advance beyond the House. The Senate is not expected to consider a reconciliation bill because it is not expected to approve a budget resolution.

AMA Plus 100 State & Specialty Societies Comment on EHR MU Program

On May 7 the AMA together with 100 state and specialty societies submitted a comment letter to the CMS making several recommendations for how to improve the Electronic Health Record (EHR) Meaningful Use program in response to a proposed rule on Stage 2. Included among these recommendations the comments championed the need for a robust evaluation of Stage 1, avoiding high reporting measure thresholds, removing any measures that are outside a physician’s control, only requiring measures that are relevant to a physician’s practice, streamlining the number of requirements, including adequate exclusions, and reporting on six clinically relevant quality measures covering at least two domains. The comments also advocated for removing any “back-dating” of penalties and the overall need for greater synchronization among all Medicare reporting programs.

The AMA also submitted a comment letter the same day to the Office of the National Coordinator for Health IT (ONC) in response to a proposed rule on the standards vendors must meet for providing certified EHRs to physicians. The AMA continues to advocate strongly for a greater focus on EHR usability and patient safety issues.

Medicare Now Accepts Physician Enrollment Applications 60 Days in Advance

For years the AMA has been pushing CMS to expand the time frame physicians have to submit their enrollment application. Until recently physicians were only permitted to send their application to their Medicare contractor 30 days in advance of the “effective date” which is the later of: 1) the date a physician filed an application that is ultimately approved by Medicare; or 2) the date a physician began furnishing services at a new practice location. Under new guidelines CMS has extended this date to 60 days, with some exceptions. The change is effective May 14.

AMA Tackles Physician Concerns with UnitedHealth Group

The AMA Practice Management Federation Staff Advisory Steering Committee (Committee) and Federation workgroups held their annual in-person meeting on May 3, 2012. The goal of this meeting is to: 1) discuss how to best address national payer trends; and 2) develop a plan of action to address practice management issues within the physician practice. The Committee and Federation workgroups also held their annual meeting with UnitedHealth Group (UHG) on May 4, 2012, to address current issues physician members have with UHG. Since these meetings began in 2007, 55 issues have been resolved and the groups have collaborated on 48 issues that have seen improvement. This year’s meetings were held at the AMA headquarters in Chicago and were attended by 25 Federation staff members representing 14 state medical associations, one county medical association and six national specialty societies, along with 18 representatives from UHG. Future efforts between the AMA, Committee, Federation workgroups and UHG will focus on developing action plans for collaborative ways to contain rising U.S. health care costs and to educate physicians on delivery system innovations.

Medicare Doctor Pay Patch Sets Up 32% Cut for 2013

Wed, 29 Feb 2012 14:30:18 GMT

The 10-month postponement of cuts to Medicare physician payment rates leaves Congress in what some see as its toughest spot to date when it comes to preventing deep pay reductions.

Lawmakers missed a major opportunity to pass a long-term solution to the broken Medicare sustainable growth rate formula. The pursuit of yet another short-term patch makes attaining a permanent fix to the SGR in 2012 significantly more difficult, with the price of a repeal going even higher above the $300 billion mark and the added pressures of competing for legislative attention in a presidential election year.

A payroll tax reduction extension package approved by Congress and signed into law on Feb. 22 by President Obama also freezes Medicare doctor pay rates for the rest of 2012. Medicare pay was set to decrease by 27.4% on March 1 after Congress had postponed the SGR cut for only two months in December 2011. But keeping rates stable only through the end of the year means that pay is scheduled to decrease by an estimated 32% in January 2013.

AMA and CMA have strongly criticized the temporary fix. Organized medicine made a concerted bid for Congress to break the cycle of payment patches by using funds projected to be saved from winding down the wars in Afghanistan and Iraq to eliminate the SGR formula, which has threatened reductions to Medicare rates since 2002. But lawmakers rejected that strategy, instead passing legislation that spends roughly $20 billion to postpone the cut and extend other Medicare pay provisions for only 10 months, while increasing the cost of a permanent solution by about $25 billion.

What it takes to buy 10 months of Medicare pay relief

As part of the most recent Medicare physician pay patch, lawmakers used cuts to hospitals, labs and other areas to offset the $17.3 billion cost of freezing doctor rates for 10 months, as well as the cost of additional Medicare pay extenders in the measure.

$6.9 billion through reduced funding to hospitals for unpaid Medicare co-pays and deductibles.
$5 billion through reduced funding for the prevention and public health fund created by the health system reform law.
$4.1 billion through rebased payments for hospitals serving a disproportionate number of low-income patients.
$2.5 billion through rescinding enhanced Medicaid pay to Louisiana under the health system reform law.
$2.4 billion through rebased payments for Medicare clinical laboratory services.

Source: American Medical News, February 27, 2012.

New Medicare Patient Preventive and Wellness Services Resource

Fri, 03 Feb 2012 12:58:32 GMT

Medicare reimburses physicians $70 for a typical patient visit. However, doctors can earn more than twice that—$166—for conducting a patient's initial wellness visit. Subsequent annual wellness visits pay more as well this year, with Medicare reimbursing physicians nearly $111 for each one.

These higher payments illustrate the importance of wellness visits, because receiving preventive and wellness services is the best way for patients, especially those on Medicare, to take care of themselves. To help physicians encourage their Medicare patients to take full advantage of the preventive and wellness services available to them, the AMA and AARP, in collaboration with the Centers for Disease Control and Prevention, developed a new resource, the "Team Up to Stay Healthy" brochure. It spells out exactly what patients need to know about their preventive and wellness benefits available through Medicare. The brochure:

Explains in clear, simple language the types of physician visits covered by Medicare.
Helps patients adequately prepare for their physician visits.
Gives patients a brief overview of common preventive screenings.
Offers patients access to more information and helpful resources about their covered services.

Keeping Medicare patients informed about their preventive service options is a matter of teamwork between patient and physician. By communicating clearly about these services, physicians can help patients better understand how and when to receive the preventive service, what is covered and charged, and the overall importance of preventive services.

CMA Urges Congress to Use Unspent Military Funds to Repeal Medicare SGR; Bipartisan Congressional Support Growing

Tue, 24 Jan 2012 16:09:07 GMT

SFMS/CMA and other health care organizations called on the Congressional Conference Committee working to craft an agreement on the 2012 tax bill between the House and the Senate to permanently stop the scheduled cuts and short-term patches to the Medicare fee-for-service program by eliminating the sustainable growth rate (SRG) formula. Two strong physician advocates from California were named to the conference committee—Congressman Henry Waxman (D-LA), the ranking minority member on the House Energy Commerce Committee, and Congressman Xavier Becerra (D-LA), the fourth-ranking Democrat in the House of Representatives. Along with the American Medical Association (AMA), SFMS/CMA sent a letter to the Congressional Conference Committee currently addressing this issue. In addition to asking for an end to the SGR, the letter asks Congress to use projected spending that will not be needed as the wars in Iraq and Afghanistan wind down to help pay for ensuring access to health care for military families and seniors on Medicare. With the early troop withdrawals in Iraq and Afghanistan, there are hundreds of billions in savings in the Overseas Contingency Operations (OCO) account. Last week, House Democratic leaders, including Congressmen Waxman and Becerra, joined a growing group of Republican and Democratic Senators in supporting the use of OCO funds to repeal the SGR. With a 27 percent cut scheduled to take effect March 1, 2012, the letter also asks the committee to act now before the cost to taxpayers grows. As recently as 2005, the cost of permanent repeal would have been $48 billion. Today the cost is estimated to be nearly $300 billion. The cost is expected to double again in the next five years. Poll results show that an overwhelming number of Americans, 94 percent, believe a massive Medicare cut, like the one scheduled for March 1, is a serious problem for seniors. Congress’s own Medicare advisory committee has said that one in four seniors seeking a new primary care physician in Medicare has had trouble finding one. In repealing the SGR, Congress will be able to bring stability to programs that are necessary to some of the most vulnerable of our patients. Please help the campaign by contacting Senators Dianne Feinstein and Barbara Boxer and ask them to protect access to care in California by using OCO funds to repeal the Medicare SGR. Let them know that that SGR cuts must be stopped before the March 1 deadline. Using the AMA Grassroots Hotline at (800) 833 635, plug in your ZIP code and you will automatically be connected to your Senator.

House Passes HR 3630, Medicare SGR Bill

Tue, 13 Dec 2011 17:11:04 GMT

This evening, the House of Representatives passed HR 3630, the “Middle Class Tax Relief and Job Creation Act of 2011,” by a vote of 234 to 193. In addition to proposals to extend the pay-roll tax cut and Unemployment Insurance (UI) programs, the bill included a proposal to provide two years of Medicare SGR relief with one percent increases in each year. The Senate Democratic leader has indicated that the House proposal does not have the support to prevail in the Senate. Additionally, the White House today announced that should the President be presented with the bill, he would veto it. Senate and White House objections mostly revolve around provisions used to pay for the House bill as well as a provision requiring the President to make a determination on the future of the controversial Keystone pipeline. AMA, CMA, and county medical societies did not support the House bill. We noted in a statement issued last week that the two year extension and modest updates would provide needed stability for physicians. However, the continued utilization of so-called “cliff financing” to hold the cost of the SGR provision to $39 billion would result in a 2014 payment cut of 37% and increase the cost of repealing the SGR by more than $60 billion to a total of greater than $350 billion. In the coming days, the Senate will likely unveil their proposal to address the pay-roll tax, UI, and the SGR. We will continue to provide you with updates as the final days of the current session of Congress wind down. CMA is in close contact with our Senators as they develop the Senate alternative this week. Please continue those calls and emails to Senators Feinstein and Boxer. Please ask your Medicare patients to make calls as well by using the CMA patient flyer on our website. Congress cannot go home without stopping the Medicare SGR fee-for-service payment cut! Please use the AMA hotline at (800) 833-6354. Enter your ZIP code and it will automatically connect you to your Representative. Please call the hotline again to reach Senators Boxer and Feinstein. You can also send emails via https://writerep.house.gov, www.boxer.senate.gov and www.feinstein.senate.gov. The sheer volume of calls is important so Congress knows you are watching closely and they must act.

Weighing Your Medicare Participation Options

Tue, 13 Dec 2011 10:48:15 GMT

Physicians have until December 31 to change your Medicare participation status for 2012. Under the Medicare rules, physicians may be classified as participating, non-participating, or opted-out of the Medicare program.

Participating: You agree to accept assignment and the amount approved by Medicare as total payment for covered services.
Non-Participating: You can choose whether to accept assignment on a per claim basis, and that you agree to accept 95% of the “par” amount on assigned claims and to charge no more than 115% of the non-par amount on non-assigned claims.
Opt-out: You have formally notified Medicare using an approved affidavit that you will not treat any non-emergent Medicare patients unless you have first entered into a private contract with them.

To assist physicians in determining the correct Medicare participation status for 2012, the AMA has developed Know your options: Medicare participation guide. The online kit contains a detailed explanation of physician options, a calculator, and various sample materials for communicating with patients.

AMA Adopts First 2011 Policy from SFMS Regarding "Crisis Pregnancy Centers"

Wed, 16 Nov 2011 09:51:45 GMT

At their interim meeting last week, the American Medical Association (AMA) adopted an SFMS resolution regarding the controversial issue "crisis pregnancy center" and the (lack of) service it provided. This issue has been debated locally and the resolution, authored by SFMS delegate Leslie Lopato, MD, and staff member Steve Heilig, MPH, was adopted by the CMA House of Delegates in October. The AMA policy states:

AMA supports regulations that require any entity offering crisis pregnancy services to disclose information onsite, in its advertising, and before any services are provided concerning the medical services, contraception, termination of pregnancy or referral for services, adoption options or referral for such services; and,
AMA advocates for any entity providing medical or health services to pregnant women who market medical or any clinical services need to abide by licensing requirements and have the appropriate qualified licensed personnel to do so and abide by federal health information privacy laws.

Summary of CMS Final Regulations on Medicare Shared Savings/ACO Program

Mon, 24 Oct 2011 17:04:30 GMT

Last week, CMS released its final rule on the Medicare Shared Savings/ACO program which was outlined in our October 20 post “HHS Releases Final Regulations For Accountable Care Organizations.” Also released was a new Advanced Payment initiative specifically for physician organizations, a final FTC-DOJ Policy Statement on Antitrust Enforcement for Medicare ACOs, and an Interim Final Rule on fraud waivers for Medicare ACOs. Based on AMA’s preliminary review, there are significant changes to the Final Rules and significant advocacy wins for the AMA and physicians. While AMA staff is now reviewing in detail, the following changes have been made to the rule that are very positive and reflect AMA comments on the proposed rules:

ACO Payment and Structure

The standard financial model for ACOs will still be shared savings, i.e., there will be no change in the underlying payment system, and the program will function essentially as a pay-for-performance program based on total cost. However, they are creating a complementary program through the Innovation Center to provide “Advance Payments” specifically to physician organizations and rural providers that do not have the capital reserves available to finance needed changes in care processes or to cover short-term losses while waiting for shared savings payments to be made.
There will still be two different tracks for ACOs, but one will be “upside only” during the three-year contract period, i.e., the ACO will not be liable to pay CMS if costs actually increase. The second will be both upside and downside, as in the proposed rule. (The proposed rule made ACOs even in the first track liable to pay CMS back for cost increases in the third year.)
There will no longer be requirements to withhold shared savings payments to cover potential future cost increases.
ACOs will be allowed to share in savings beginning with the first dollar of savings earned. The proposed rule gave ACOs a share of savings above a minimum threshold. ACOs must still meet a minimum threshold of savings but they can earn back more of the savings they generate.
There will be 33 quality measures instead of 65, and they have dropped the Hospital Acquired Conditions (HAC) measures, as we urged. There will be no flexibility, though, for different quality measures in different regions.
They will have a more prospective method of assigning beneficiaries. ACOs will get a list of “probable beneficiaries” and the list will be updated quarterly. There will still not be mechanisms for beneficiaries to sign up voluntarily, though; the ACO will only get credit for them after the attribution methodology determines that they have had a majority of their primary care visits with the ACO. In addition, as the AMA recommended, CMS will include primary care services provided by specialist physicians in assigning patients to ACOs, and not limit the attribution method exclusively to primary care physicians.
They eliminated the requirement that at least 50 percent of an ACO’s primary care physicians must be “meaningful users” of EHRs by year 2 of the program. Instead they will double weight the quality measure "Percent of PCPs who successfully qualify for an EHR Incentive Program Payment." ACOs only have to report a percentage and not meet a specified percentage when reporting this quality measure and the term "qualify" covers PCPs who participate in either the Medicare or Medicaid EHR Incentive program.
There will be a rolling application process, so prospective ACOs will have time to prepare without having to meet arbitrary deadlines that are too short.

Antitrust

FTC-DOJ has adopted two important changes that the AMA requested:

They have eliminated the need for mandatory review of ACOs above the 50 percent threshold of the primary service area (PSA) calculation. While the Agencies will still rely on the PSA calculation, eliminating mandatory review will result in significant removal of burden and cost on potential ACOs.
The statement applies to ALL collaborations among otherwise independent providers. The draft statement applied only to new entities formed after March 23, 2010. This would have placed all collaborations that existed prior to March 23, 2010 under a separate antitrust review system.

Fraud Waivers

CMS and the Office of Inspector General adopted the AMA recommendations that the waivers begin sooner so that they will apply during the process of planning a Medicare ACO, and that ACOs will be able to offer certain additional medical benefits to patients, such as care management, without having them viewed as inappropriate inducements. In addition, the agencies issued the new waivers regulation as an interim final rule instead of a final rule, as the AMA had recommended.

links to key documents

Medicare Tests Monthly Incentives for Innovative Primary Care

Tue, 11 Oct 2011 16:30:36 GMT

Participating practices will receive an average of about $20 per patient per month to coordinate quality care for Medicare and private patients.

Medicare will partner with private insurers to offer physicians patient management fees and the opportunity to share savings under a primary care payment initiative led by the Centers for Medicare & Medicaid Services. The Comprehensive Primary Care Initiative is a new collaboration between public and private payers to strengthen primary care. The Center for Medicare & Medicaid Innovation is inviting insurers to join government health plans in trying a new approach to paying for primary care starting in 2012. "We believe that if we can give primary care clinicians the time and resources to take care of their patients and coordinate their care across the spectrum, in the end we'll get happier and healthier patients," said Richard Gilfillan, MD, acting director of the innovation center. "We know we'll get providers who feel more fulfilled. And we know over time we'll improve overall costs of the system and make the system more sustainable." The initiative is designed to enhance the work being done by payers who have developed innovative models to pay for coordinated care and higher quality services, such as the patient-centered medical home. The Medicare agency wants to pay more for outpatient services that keep patients healthier and prevent costlier inpatient care. For instance, care coordination in the Community Care of North Carolina program, which initially launched as a Medicaid medical home project, has been able to lower preventable hospitalizations significantly for patients with chronic conditions, according to CMS. Once the participating private payers are selected, interested physician practices will be asked to apply through CMS to participate. CMS will require practices to provide comprehensive primary care services to Medicare patients and to those with coverage from a participating payer. Preference will be given to practices that have achieved meaningful use of an electronic medical record system, according to the application materials. Practices will receive patient management fees to pay for the new health care delivery methods, said Richard Baron, MD, director of the Seamless Care Models Group at the innovation center. This fee is expected to average about $20 per month for each patient covered by one of the participating payers. CMS also will provide practices with patient and resource use data so patients have more information on the quality of their care and their physicians' performance. Any savings that might be generated for the Medicare program would be shared with the practices.

Trying to transform primary care

CMS plans to select up to seven areas of the U.S. to participate in the demonstration, which will launch in the summer of 2012. Each market will include about 75 practices caring for roughly 300,000 Medicare or Medicaid patients over four years. Those participating in the initiative can't participate in other shared savings initiatives, such as the forthcoming Medicare accountable care organization program.

TAKE ACTION NOW!! Urge Congress to Repeal the Medicare SGR and Prevent Further Cuts to Medi-Cal

Wed, 05 Oct 2011 13:31:54 GMT

Congress has appointed a Joint Select Committee on Deficit Reduction to develop $1.5 trillion in spending cuts/revenue increases by Thanksgiving. On January 1, 2012, physicians face a 30 percent Medicare sustainable growth rate (SGR) payment cut. The San Francisco Medical Society and California Medical Association (CMA) are joining the American Medical Association, state medical associations, and national medical specialty societies in a united campaign to get a permanent repeal of the flawed Medicare SGR formula included in the deficit reduction package that is currently being developed by Congress’ Joint Select Committee on Deficit Reduction. The deficit reduction committee is also considering proposals that would reduce federal matching funds for California’s Medi-Cal and Healthy Families programs. Decreases in federal expenditures would force California to further reduce physician payment rates and increase patient co-payments. SFMS, CMA, and the physicians of California are extremely concerned that additional cuts to already low payment rates will exacerbate the current access to care problems and cause irreparable harm to patients. There is unanimous agreement that cuts of this magnitude would result in serious disruptions in care for the nation’s elderly and disabled populations, and cannot be allowed to occur. We are asking Congress to repeal the SGR and work with us over the next few years to test and develop alternative payment models and health care delivery systems that ensure access to efficient, appropriate, high-quality, coordinated care. We believe that stable reimbursement in these programs not only protects access to care but also makes economic sense as physicians are important employers in their communities and repealing the SGR saves hundreds of billions of dollars. Physicians have been running a Medicare SGR marathon with Congress for the last decade. We are close to the finish line and need to make one last sprint! It’s NOW OR NEVER!

CONTACT CONGRESS TODAY!

EMAIL Senators Boxer and Feinstein through http://writerep.house.gov; www.boxer.senate.gov and www.feinstein.senate.gov. Also contact Congressman Becerra (D-LA), a member of the Deficit Committee at www.becerra.house.gov. Messages can also be sent to California Representatives who are in leadership positions: House Whip-Congressman Kevin McCarthy www.kevinmccarthy.house.gov; and House Minority Leader-Congresswoman Nancy Pelosi www.pelosi.house.gov. USE THE AMA GRASSROOTS HOTLINE at (800) 833-6354 to call your Representative and Senators Boxer and Feinstein. Key in your zip code and you will be connected to your Senator/Representative. Please state your name, specialty and city/county in which you practice, and urge them to:

Repeal the Medicare SGR in the deficit committee legislation
Stop further Medi-Cal physician payment cuts
Protect access to care for California’s most vulnerable patients: Seniors, military families, the disabled, pregnant women and children

Click here for background information about this issue.

Click here for a list of talking points.

Click here for a sample letter to your Representative or Senator.

Click here for legislators' contact information.

Supreme Court to Hear Oral Arguments in Douglas v. Independent Living Center of Southern California, et al.

Wed, 28 Sep 2011 16:04:29 GMT

This case will determine whether or not patients and providers can legally advocate for themselves

On October 3, 2011 the U.S. Supreme Court will hear oral arguments in the Douglas v. Independent Living Center of Southern California ("Independent Living Center") case. The Supreme Court’s ruling could have huge implications for the more than 10 million patients in California that are currently enrolled in California’s Medicaid program, as well as for the physicians that voluntarily treat those patients. The California Medical Association (CMA) is a party in the case. The issue addressed by Douglas v. Independent Living Center is whether or not Medicaid recipients and providers can sue a state for failing to pay the rates required by the Medicaid Act, which states that government insured and privately insured patients have equal access to medical care. As the Supreme Court hears the case, a number of state plan amendments (SPAs) submitted by the State of California sit with the Centers for Medicaid and Medicare Services (CMS). The SPAs each propose significant cuts to California’s Medicaid program, Medi-Cal. The SPAs would, among other things, cut physician reimbursement, limit the number of times a patient can see a physician per year, and implement mandatory patient co-pays. “The state plan amendments submitted by California to CMS would severely reduce Medi-Cal patients' access to medical care,” Francisco Silva, CMA General Counsel and Vice President said. “The proposed cuts would mean that a primary care physician would only be reimbursed $11 for a Medi-Cal patient visit. Physicians have to pay their staffs and keep their doors open, and these rates would just not allow for them to do that and accept Medi-Cal Patients.” Medi-Cal provides essential health care services to the poorest and most vulnerable Californians. Through Medi-Cal, physicians, dentists, pharmacists, adult day health care providers, clinics, and hospitals provide health care services to low-income seniors, families, children, and people with disabilities. By providing these primary and preventive care services, the state ensures these Californians have access to health care, while at the same time saving money by lowering the chances they will be forced to seek more costly health care, such as emergency rooms or hospital admissions. “The issue before the U.S. Supreme Court is crucial to the future of how patient advocacy will unfold,” said Theodore Mazer, MD. “If patients can’t fight for themselves, and as physicians, we can’t either--then who is left to stand up for the group of people that needs our help the most?” Mazer, a San Diego otolaryngologist treated Medi-Cal enrollees for over 20 years until the state began seeking reimbursement cuts. 18 months ago, he stopped accepting new Medi-Cal patients. He is an individual party in the lawsuit. “It’s unfortunate that the State has made us choose between accepting new Medi-Cal patients and keeping our practices viable,” Mazer added. In 2008, a coalition of health care providers including CMA sued the state of California to stop a 10% cut in Medi-Cal reimbursements. A federal appeals court ruled that Medi-Cal providers have standing to challenge the state’s rate cut and upheld the merits of the 2008 preliminary injunction that forced the state to immediately reverse the cut. The U.S. Supreme is considering this case and others with respect to whether providers and patients have legal standing to enforce the federal Medicaid law. A number of amicus briefs have been filed in support of respondents in the case, including:

List of SFMS Resolutions Submitted to 2011 CMA House of Delegates

Tue, 27 Sep 2011 15:16:09 GMT

By Stephen Follansbee, MD and Steve Heilig, MPH The California Medical Association can be a formidable force in Sacramento health policy. The CMA House of Delegations meeting, scheduled for October this year, is the opportunity for physicians to guide the CMA on important issues and set the priority for these efforts. Your elected SFMS delegates have introduced a roster of policy resolutions to be debated at the meeting. As your representatives, we thought you might like to see what we will be addressing – along with the many other resolutions introduced from other delegations throughout the state. The SFMS is a relatively small but relatively “loud” presence each year, with a good track record of successful policies; here is our list. In November we will publish a scorecard on what we were able to get adopted; and then the real work begins in the halls of politics, translating these words into something that benefits patients, the public, and physicians all over our state – and beyond as some of these would then be referred on to the AMA.

SFMS Proposed Policies for 2011 (authors in italics):

Reduction of Subsidies of Tobacco in Films (Fung): Did you know that the movie industry gets big tax credits for filming, including when they portray tobacco use? UCSF researchers have shown this is true – that taxpayers subsidize tobacco marketing, in effect – and we hope to stop that. Unethical Rebates from Pharmaceutical Companies (Susens): Some drug makers still offer money to doctors who prescribe their products. Some doctors take that money. This is against ethical codes and we hope to stop that. Deceptive Pregnancy ‘Crisis/Counseling’ Centers (Lopato): As reported in the Chronicle, certain “clinics” are in fact “pro-life" centers which seek to divert women from considering abortion with misinformation and fear. We would require full disclosure of what is and is not offered at such places. Regulation of Electronic Cigarettes (Fouras, Aragon): These nicotine delivery devices may have their place as harm reduction, but they need more regulation for both users and the public, and this resolution would require that. Supporting The California Cancer Research Act (Margolin): The CRCA will be on the ballot, increasing tobacco taxes for cancer research, and we ask the CMA to join the full-court press to help it pass in this "no new taxes” era. Clinical Research - Banning "Seeding" and Similar Marketing Trials (Susens): Pharmaceutical companies do marketing in the guise of “research” even after the medication is approved, with unwarranted cost and safety implications; we hope to stop that. Healthy Food Marketing for Children (Desai, Schickedanz, Udovic-Constant): The obesity epidemic too often starts in childhood, and better “selling” of healthy food is indicated; this would encourage that on various fronts. Opposing Legal Prohibition of Circumcision (Tabas): This intrusion was blocked from the state ballot, but will likely be back, and we want CMA and AMA on record in opposition for next time. Firearms and Censorship (Follansbee): Another intrusion, courtesy of the gun lobby, prohibits Florida physicians from even talking with patients about the risk of guns in the home. We hope to stop this there and before it spreads. Contraception as a Fully-Covered Health Insurance Benefit (Silverman, Desai, Myers): This has now been adopted as national policy, but attempts to overturn it are already promised. We want CMA and AMA on record in support of full coverage. Increasing Organ Donation via Presumed Consent (Follansbee, Margolin): The waiting lines for organs get longer, and more people die while waiting. It is time for some changes in organ policy and we are asking CMA to weigh in, based upon evidence, ethics, and what some other nations are doing. Clinical Sense and Costs at the FDA; Generic vs. Brand Medications (Susens): When a generic medication mysteriously goes back to “brand," and the price skyrockets, that seems wrong, and we think the FDA should take a closer look. Vision Screening for School-Aged Children (Leung): Too much pediatric poor vision is missed, and schools may be a good place to screen for that and refer to early intervention. Emergency Department Overcrowding (Maa, Curran): When emergency departments get too crowded, some hospitals have “triaged” based on financial considerations. That’s not good; there must be better ways, and we'll ask CMA to try to find them. As you can see, it's a full and diverse roster. As already mentioned, there will be much more from other delegates around the state; any CMA member can propose a resolution, and perhaps we can help you bring good ideas forward next year. As for this year, stay tuned. Stephen Follansbee is an SFMS past-president, chairs the SFMS delegation to the CMA, and is an infectious disease specialist at Kaiser San Francisco and a clinical professor at UCSF. Steve Heilig is on the SFMS staff.