ACEP 911 Network Weekly Update, November 10, 2017

House Committee Reviews MACRA and APMs
On Wednesday, the House Energy and Commerce Health Subcommittee held a hearing to evaluate the transition to value based care for physicians, including the development of Alternative Payment Models (APMs) established under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The first panel included Dr. Jeffrey Bailet and Ms. Elizabeth Mitchell, the respective Chair and Vice-Chair of the Physician-Focused Payment Model Technical Advisory Committee (PTAC). PTAC oversees new Medicare payment models before submitting them to HHS. Dr. Bailet and Ms. Mitchell outlined three barriers to establishing effective alternatives: the need for technical assistance to help physicians transition from fee-for-service to value-based care; greater access to shared data; and the need to test new, small-scale models. The second panel included stakeholders, including some physician organizations, who are already using APMs.

ACEP has been in contact with the committee and offered to share our expertise and experience in developing the successful Clinical Emergency Data Registry (CEDR) , which supports emergency physicians’ efforts to improve quality and practice in all types of emergency department settings.

To view the hearing, click here .

Individual Mandate Repeal Left Out of Tax Reform Proposals – For Now
As congressional legislators prepared their tax reform proposal this week, rumors and speculation swirled about the possible inclusion of a repeal of the Affordable Care Act’s (ACA) individual mandate to purchase health insurance coverage. Several GOP members have been pushing Republican leadership to include the repeal both to help pay for the tax reform package and to deliver a victory on the broader ACA repeal effort, but neither the bill approved by the House Ways & Means Committee on Thursday or the proposal released by the Senate this include the provision. However, the White House is reportedly supportive of the individual mandate repeal being included, and legislators continue to push behind the scenes to amend the tax reform package to include it, so much can change as the process continues.

A new estimate issued by the Congressional Budget Office this week indicates that the repeal would save $338 billion but result in 13 million more uninsured individuals over the next decade. Throughout the health care reform debate this year, ACEP has opposed efforts that result in fewer individuals with insurance coverage, as the burdens of increased patient loads and crowding ultimately fall on emergency departments across the country and patient care suffers as a result. ACEP continues to monitor this effort and work with legislators to advocate for solutions that improve patient access to care.

CMS Administrator Seema Verma Lays Out Medicaid Changes
In remarks delivered to the National Association of Medicaid Directors on Tuesday, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma laid out plans to allow for significant changes to the Medicaid program, most notably by allowing states to impose work requirements for enrollees. In addition to streamlining and reducing the burdens of the waiver process, CMS intends to approve state waivers that include “community engagement” requirements such as volunteer work or job training.

Several states, including Kentucky and Indiana, are expected to seek waivers to establish work requirements. Verma also indicated the Administration is prepared for the inevitable legal challenges that have been threatened by opponents of work requirements.

ACEP policy advocates for health coverage that provides timely, unrestricted access to quality emergency care, and will continue to monitor any changes to the health care safety net provided under the Medicaid program.

Health Care Reform’s Role in the Nov. 7 Statewide Elections
Voter support of the ACA played a role in the Governor’s race in Virginia and a ballot initiative in Maine in this week’s elections. Nearly four in 10 Virginia voters listed health care as their top policy issue, according to CNN—and 77% of those voters broke for Democrat Ralph Northam who handily defeated Republican Ed Gillespie to become Virginia’s next Governor. But the more surprising element of the Virginia election results may be that Democrats flipped about a dozen seats in the Republican-dominated Virginia House of Delegates. Several of those races are still too close to call or may require recounts, but when all the votes are tallied, it appears the makeup of the House will be much closer to 50-50. An evenly matched Democrat-Republican split in the state Senate and the Democratic victories for governor, lieutenant governor, and attorney general—could reshape the politics of Medicaid expansion in Virginia as well. Outgoing Virginia Democratic Gov. Terry McAuliffe has tried multiple times to strike a Medicaid deal with the GOP state legislature but as been consistently rebuffed; expanding the program would extend health coverage to an estimated 400,000 Virginians.

And in Maine, voters in a landslide backed a ballot initiative that would expand Medicaid, an initiative that the Republican Governor LePage had vetoed on five separate occasions. About 60% of Maine voters approved the Medicaid ballot measure, which would extend health insurance coverage to about 70,000 low-income state residents and their families.

Medicaid expansion has consistently been one of the ACA’s most popular measures. LePage, however, is already signaling that he won’t implement it despite the overwhelming popular referendum results until it has been fully funded by the Legislature at the levels the HHS has calculated.

Healthcare Law Update — State of Reform Conference Report

I recently attended the annual State of Reform Health Policy Conference.

I have attended this conference each year since its inception.  This year 293 attended and there were 57 speakers.  Despite the highest attendance on record the mood was noticeably more negative than past years.  Many healthcare policy discussions turned quickly to that of Alaska’s budget crisis and speculation on how the budget will impact both public and private healthcare.  On the global scale much time was devoted to whether or not the ACA will be repealed and replaced and when such action may occur.  Senator Sullivan indicated that he foresees no action on healthcare until after January 1.

The conference is divided into 3 tracks of 5 sessions.  I typically select tracks and sessions that I think relevant to most clients.  This year I found most sessions to be lacking in the practicality and found little advancement of either policy reform or operational reform that a practitioner can implement.

Key takeaways:

1)      Universal concern for Alaska’s budget instability.  While this is no surprise, what is new is that most practitioners are no-longer decoupling the lack of a balanced State budget from the actual health of the Alaska economy.  Now the two are discussed in conjunction and there is real concern.

2)      Commercial payors are acknowledging that Alaska is on an unsustainable trajectory of premium costs.  Payors continue to blame providers for this cost, but now they are openly admitting that the market cannot sustain (in the individual and small group) current or anticipated premiums.  Payors are now suggesting new Coordinated Care Organization and Accountable Care Organization models.  Moda in particular is pressing for the CCO model and points to its early success with this approach in Oregon.  Given Moda’s tremendous instability, it is difficult to look to this payor as a guiding light.  But, the takeaway is that all payors are now openly discussing these alternatives.

3)      Commercial payors are signaling that the fee-for-service contract model will terminate likely in the next 2-3 years.  This means that providers must prepare for value-based contracting and even those providers who are not participating in CMS or the MIPS program will likely have to participate in MIPS-like reporting as a condition of contracting.  The rationale being many providers do participate in CMS and MIPS and that the commercial payors are reluctant to introduce new quality reporting criteria.  So, while the federal healthcare policy is allegedly not a single payor system, we take another step in that direction though the adoption of CMS criteria by commercial payors.

4)      Price transparency. The municipal attorney made a short and concise presentation on AO 2017-26 (the subject of my March 13, 2017 Update).  Representative Andy Josephson (D – Anchorage) presented HB 123, the House price transparency bill.  In sum, HB 123 is not as sophisticated as AO 2017-26 and for those providers in Anchorage, compliance with AO 2017-26 will result in compliance with HB 123.  That said, HB 123 may be taken up in January by the Legislature  and may change in substance before passage.  I’ll keep you posted on developments.

5)      The 80th Percentile Rule. (See my Updates dated December 8, 2016 and January 10, 2017). On the discussion panel was Lauren Cover, a contracting consultant with Aldrich; Dr. Graham Glass, immediate past president of the Alaska State Medical Association, but who quickly clarified that he was appearing in his personal capacity; and Albert Fogel, an employee benefits consultant with Northrim Benefits Group.  Surprisingly Dr. Glass supports significant revision of the rule or even outright repeal.  Not surprising is that Aldrich, which is in the business of negotiating payor contracts, and Northrim Benefits Group, which is in the business of selling health insurance, both support repeal. The push back from the provider attendees was spirited.  Most disheartening on this issue were statements by State Senator Cathy Giessel made during the lunch keynote in which she indicated that she would introduce legislation to repeal the rule this January.  However, Alaska Division of Insurance Director, Lori Wing-Heier, in her closing comments indicated a far more informed understanding of the rule, its intent and effect on the patient. 10 months after the initial scoping hearing on the issue and Director Wing-Heier appears to be supportive of the rule and might turn out to be the most important champion of out of network providers.

6)      Providers seek alternative practice models. While not a topic of any panel, my discussions with clients and non-clients at the conference confirm that providers are becoming exhausted by over-regulation and uncertainty of future regulation.  They seek alternative practice models that avoid participation in government healthcare plans and now even avoidance of commercial payors. Some alternative models include subscriber-based medicine.  This model works best with established volume primary care or occupational medicine practice.  Is this a solution to the Alaska crisis? Likely not on a large scale.  Alaska will continue to need providers willing to participate in government programs due to the sheer numbers of beneficiaries.  However, it may be a solution for some frustrated providers. I am researching various models and will share in a future Update.


Peter M. Diemer