California Medical Association

Friday, May 22, 2015

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Providing news to the San Francisco Medical Community.


Meaningful Use Proposals: Opportunity for Physician Comment

Public comment is open for three recently published notices of proposed rulemaking that intend to restructure the Electronic Health Record Incentive Program (meaningful use) requirements starting this year through 2017, as well as define Stage 3 meaningful use, set to begin in 2018.

CMS and the Office of the National Coordinator for Health IT’s proposed changes will affect more than 538,000 active program registrants and the developers of more than 2,600 health IT products currently used to meet meaningful use. The meaningful use program will continue to affect care delivery in the U.S. health care system as a whole with the potential to improve patient outcomes.

Physicians can influence program changes by submitting comment electronically via http://www.regulations.gov and follow the “Submit a comment” instructions.

Top Three Stage 3 Takeaways and Ideas for Public Comment -- Due May 29, 2015

The sum of the CMS Stage 3 NPRM and meaningful use-related components of the ONC 2015 Certified EHR Technology NPRM are that Stage 3 will be more challenging and complex than Stage 2, with ambitious thresholds, opportunities to upgrade and innovate with new technologies and/or require new workflows for providers. Our top three takeaways reflect the fundamental tenets of the meaningful use program that remain intact.

  1. Unclear CEHRT upgrade timing. All providers must implement 2015 Edition certified EHR technology for the 2018 reporting year. CMS' proposed timeline is such that providers must meet year-long performance requirements in consecutive years (i.e., 2016, 2017 and 2018). As a result, it is difficult for providers to identify the optimal timing for the CEHRT upgrade, even with a shorter reporting period proposed for 2015. For example, a CEHRT upgrade that occurs in the first quarter of 2016 may not be fully implemented until mid-year. That timing could impede a provider's ability to meet year-long meaningful use performance metrics. Readying current technology to meet the aggressive Jan. 1, 2018, deadline may lead to development challenges for health IT developers.
  2. High thresholds proposed. CMS proposes eight objectives with 16 measures for EPs and 17 for EHs, the majority of which set higher thresholds than those finalized in the existing Stage 2 regulation. Providers may disagree with those new bars for performance. We suggest that they offer concrete case examples that support their positions. For example, the Secure Electronic Messaging measure increases from 5% to 35%, which assumes a high patient portal or personal health record adoption level among patients. Providers may wish to provide comment regarding the difficulties in their patient engagement efforts, especially the challenges among the majority of patient populations to whom the providers render care.  
  3. Electronic clinical quality measure reporting mandated in 2018. CMS proposes to mandate electronic clinical quality measure reporting starting in 2018. This proposal continues CMS' efforts to align quality reporting requirements across programs. CMS will specify the required measures providers report in separate, future rulemakings (i.e., the Medicare Physician Fee Schedule and Inpatient Prospective Payment Systems rules). Providers and health IT developers alike may want to describe to CMS the significant efforts required to develop and implement updated electronic CQM specifications. Providers may require new data capture workflows in multiple settings across their care delivery process to ensure completion of data. In addition, providers have to perform data validation to ensure the accuracy of their performance. Based on our anecdotal evidence, we understand the process is extremely resource intensive for both sets of stakeholders.

Top Three 2015‒2017 Meaningful Use Modification Takeaways and Ideas for Public Comment -- Due June 15, 2015

The 2015‒2017 Modifications NPRM  proposes to drastically modify meaningful use requirements for providers. The proposal aims to simplify program requirements, reduce reporting burdens and align with the Stage 3 NPRMs. 

  1. Program year and reporting periods changed. CMS proposes to modify the program year for EHs from a fiscal year to a calendar year to align with the program year schedule that EPs follow. In addition, it offers a shortened reporting period of any consecutive 90 days for all providers in 2015. This is the last proposed 90-day reporting period for providers past their first year of meaningful use in the program's foreseeable future. Providers may wish to commend CMS on these changes and encourage them to finalize them exactly as proposed. 
  2. Removed measures, reduced thresholds. Many providers will welcome the surprising policy changes that CMS made to reduce thresholds and remove about 40% of core measures. On the other hand, they may be unpleasantly surprised to see no change to a measure many providers struggle with: Patient Electronic Access, or the View, Download and Transmit [VDT] Measure 1 (i.e., electronic access to health information provided for more than 50% of patients seen/discharged). Our anecdotal evidence suggests providers struggle to meet this requirement because of challenges in providing access to patient information when their systems require an email address to do so and/or provider intervention to authenticate a patient's identity. As mentioned in the Stage 3 information above, providers should offer frontline case examples to support their standpoint on the lessened measure thresholds proposed for VDT Measure 2 (i.e., patients who view, download or transmit their health information) and Secure Electronic Messaging. However, they may want to suggest to CMS that other measures, such as VDT Measure 1, also deserve lessened thresholds.
  3. Potential "Modified Stage 2" complications. Some of the changes that CMS proposes may complicate a provider's ability to successfully demonstrate meaningful use. We encourage providers to explain whether or not they would be able to successfully (or not successfully) demonstrate meaningful use based on the modified policies.

Source: iHealthBeat, May 18, 2015.


California Medical Association Removes Opposition to Physician Aid in Dying Bill; SFMS Advocacy Initiates New Discussion on PAD

The California Medical Association (CMA) announced in today’s San Francisco Chronicle that it has become the first state medical association in the nation to change its position on the long-debated issue of physician-assisted dying (PAD).

SFMS has been a long-time advocate on this difficult topic. Our delegation asked CMA to consider neutrality at least three times in the past 15 years. The latest SFMS effort was a letter submitted to the CMA board in January 2015 urging a more open consideration, and after much debate the CMA Council on Legislation voted overwhelmingly in favor of neutrality.

By removing decades-old organizational policy, CMA has eliminated its historic opposition and is now officially neutral on SB 128 (Monning/Wolk), the End of Life Option Act.

“As physicians, we want to provide the best care possible for our patients. However, despite the remarkable medical breakthroughs we’ve made and the world-class hospice or palliative care we can provide, it isn’t always enough,” said CMA President Luther F. Cobb, MD. “The decision to participate in the End of Life Option Act is a very personal one between a doctor and their patient, which is why CMA has removed policy that outright objects to physicians aiding terminally ill patients in end of life options. We believe it is up to the individual physician and their patient to decide voluntarily whether the End of Life Option Act is something in which they want to engage. Protecting that physician-patient relationship is essential.”

CMA's amendments to SB 128 have been accepted by the authoring Senators, and are partly based upon clinical guidelines/safeguards developed at SFMS (and published in the April issue of San Francisco Medicine). Physicians would be explicitly protected from any sanctions for either participating or declining to participate in PAD.

Click here for a full statement from the authors of SB 128. 

Click here for the Chronicle's coverage of this historic development.


UnitedHealthcare to Alter Premium Designation Criteria

UnitedHealthcare (UHC) has altered the criteria for meeting the physician cost efficiency component of its Premium Designation program. UHC will now designate a physician as “Cost Efficient” when he or she has met the episodic cost benchmark, even if the physician did not achieve the population cost benchmark. The change only impacts those physician specialties that are evaluated on both population cost and episode cost, which include:

  • Family medicine
  • Internal medicine
  • Pediatrics
  • OB/GYN
  • Allergy
  • Cardiology
  • Endocrinology
  • Nephrology
  • Neurology
  • Pulmonology
  • Rheumatology

Surgical specialties are all excluded.

Previously, physicians who met episodic cost but failed to meet the population cost component did not receive the UHC Cost Efficiency designation in the Premium Designation assessment. The results of the modified criteria were communicated to affected physicians in a letter in March and are also available on the UHC website. This designation includes data from January 1, 2011, through February 28, 2014.

In 2014, CMA raised multiple concerns with the payor’s criteria for evaluating physician cost efficiency and urged the payor to make changes.

Physicians who have questions or concerns with their physician assessment reports or their Premium Designation can contact UHC at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve the issue with UnitedHealthcare directly should contact CMA at (916) 551-2865.

For more information on the Premium Designation program, visit the UnitedHealthcare website at www.unitedhealthcareonline.com.


Governor Brown’s 2015-16 Revised Budget Proposal and Its Impact on Health Care

Governor Brown released a revised budget proposal for fiscal year 2015-16, commonly referred to as the “May Revise.

The budget revision includes an increase in overall expenditures from the General Fund to $115.3 billion, an increase of approximately $2 billion (.06% increase) from his January proposal. Total proposed spending for the budget year is projected to be $169 billion, taking into account federal and special fund sources.

Medi-Cal

The Governor’s revised Budget contains no significant increases to Medi-Cal provider reimbursement rates. SFMS/CMA and other stakeholders have continued to point out major deficiencies in the Medi-Cal program, most notably the serious challenges that many Medi-Cal beneficiaries have accessing care.

Despite these concerns, the Governor is proposing an additional $200 million to provide full-scope Medi-Cal coverage, In-Home Supportive Services, and other benefits for the individuals who are covered by President Obama’s executive orders relating to certain undocumented immigrants. Under existing California law, an individual who is lawfully present in the state is entitled to certain health and social services. The May Revise assumes the legal challenges surrounding the President’s actions will ultimately be unsuccessful and sets aside an additional $200 million for this purpose.

The Governor is now estimating that the Medi-Cal program will serve 12.4 million people, an increase of 200,000 people since January. The May Revise assumes a $2.9 billion increase to provide coverage for Medi-Cal beneficiaries under the mandatory expansion, which would be split evenly between the state and the federal government under the traditional Medicaid financing structure. The May Revise also includes costs of $14 billion for the “optional expansion” – adults without children and parents/caretakers with incomes up to 138% of the federal poverty level. However, this population is financed entirely by the federal government until the 2016-17 fiscal year.

The Governor’s May Revise includes $341 million to cover increased mental health and substance use disorder benefits available to Medi-Cal enrollees. 

Controlled Substance Utilization Review and Evaluation System (CURES)

The administration is proposing an appropriation of $1.1 million to fund five positions for the ongoing maintenance and operations of the CURES prescription drug monitoring database. In January, SFMS/CMA urged the Legislature to continue its oversight over the CURES upgrade to ensure that the project is completed in a timely fashion and that the Department of Justice has adequate staff resources to, in a timely manner, enroll the thousands of licensees now required to apply to CURES by January 1, 2016.

High-cost Drugs

The January Budget proposal reserved $300 million to pay for several new drugs for Hepatitis C for individuals in the Medi-Cal Program, the AIDS Drug Assistance Program, inmates in state prisons, and patients in state hospitals. In the May Revise, the Budget allocates $228 million of that $300 million to the Department of Health Care Services, the Department of State Hospitals, and the Department of Corrections and Rehabilitation. Additionally, the State will convene two workgroups: one to examine high-cost drugs that are pending federal approval and how they could affect existing clinical guidelines, and another procurement workgroup that will examine pharmacy benefit manager contracts, drug pricing information, and the ability to negotiate prices and rebates.

Next Steps

The Legislature is constitutionally required to pass a balanced budget by June 15, leaving the Governor until June 30 to sign, veto, or approve the Budget with reduced expenditures (line-item veto). Both houses of the Legislature will continue to hold committee hearings on the various proposals and assumptions contained in the May Revision. Meanwhile, the Legislative leaders will begin negotiation on some of the major aspects of the Budget directly with the Governor and his administration. CMA has put several hundred hours into our advocacy surrounding Medi-Cal reimbursement rates and will ramp up those advocacy efforts over the next month.

Click here to view the 106-page May Revise. 

Application Cycle Starts Next Week for Primary Care Physicians Interested in Steven M. Thompson Physician Corps Loan Repayment Award

The Health Professions Education Foundation (HPEF), a division of the Office of Statewide Health Planning and Development, has announced a special application cycle for the Steven M. Thompson Loan Repayment Program award. Applicants for this award could receive up to $105,000 for loan repayments in exchange for a service obligation in California’s medically underserved areas or public mental health system.

HPEF will accept applications from May 18 through June 26. Primary care physicians specializing in family medicine, internal medicine, obstetrics and gynecology, and pediatrics are eligible to apply. This cycle is only open to applicants in the following 17 counties: Alameda, Kings, Orange, Stanislaus, Contra Costa, Los Angeles, Riverside, Tulare, Del Norte, Madera, Sacramento, Fresno, Merced, San Diego, Kern, Monterey, and San Joaquin.   

HPEF contracts directly with recipients and does not require employers to provide or match funds.

Click here for more information and to apply.


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