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The House of Representatives has approved H.R. 987, the “Strengthening Health Care and Lowering Prescription Drug Costs Act,” which packages seven prescription drug and insurance-related bills recently approved by the House Energy and Commerce Committee.  The legislation is intended to:  increase generic drug competition; fund Affordable Care Act “Navigator” outreach and enrollment programs and…

The opioid crisis continues to be a focus for Congressional committees. The House Energy and Commerce Committee held hearings on prevention and public health solutions to the opioid crisis, along with the Drug Enforcement Administration’s role in combating the opioid epidemic. The Senate Health, Education, Labor and Pensions (HELP) Committee held a hearing focusing on…

CMS has proposed new regulations to continue implementing the “Quality Payment Program” (QPP) — the new Medicare physician fee schedule (MPFS) update framework mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). As previously reported, starting in 2017, physicians will be paid under the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (APM).

For the second year of the QPP, CMS is proposing to continue a number of transition policies established for 2017 while “ramping up to full implementation.” Notably, with regard to the MIPS track, CMS proposes to:
Continue Reading CMS Proposes Changes for Second Year of Medicare Physician Quality Payment Program

CMS expects nearly 100% of eligible clinicians in Advanced Alternative Payment Models (APMs) to meet the Medicare Qualifying APM Participant (QP) standard for performance year 2017 and be eligible to receive a 5% APM incentive payment in 2019 under Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules. This projection is based on an…

Temporary Transition Policies Reduce Threat of Negative Adjustments in 2019, But Adds to Complexity

On November 4, 2016, the Centers for Medicare & Medicaid Services (CMS) is publishing a sweeping final rule reforming the Medicare physician fee schedule (MPFS) update framework, as mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). …

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to provide recommendations on arrangements that meet the criteria for a physician-focused payment model (PFPM) under the reformed system for updating the Medicare physician fee schedule. The PTAC has announced that it will begin accepting letters…

In a recent blog post, CMS Acting Administrator Andy Slavitt announced CMS’s plans to give physicians more options for complying with significant upcoming changes to Medicare physician fee schedule (MPFS) rules – which will help physicians avoid triggering a negative payment adjustment in the first year of the program.

As previously reported, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) repealed the longstanding sustainable growth rate methodology for updating the MPFS.  Instead, MACRA established a period of stable MPFS annual updates, after which MPFS updates will be made pursuant to either a new Merit-based Incentive Payment System (MIPS) or based on participation in qualified Alternative Payment Models (APMs).  CMS published a proposed rule in May 2016 to implement the MIPS and APM reforms, which together CMS calls the “Quality Payment Program.”  The first reporting period for the Quality Payment Program begins on January 1, 2017, and it will impact physician payment in 2019.
Continue Reading CMS Announces Flexibility for Physician First-Year Participation in MACRA Quality Payment Program

CMS is soliciting public input on the “evolution” of its State Innovation Models (SIM) Initiative, which was launched in 2013 to accelerate state design and testing of multi-payer payment and delivery models to generate savings and improve care for Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries. In a September 8, 2016 press…

The Physician-Focused Payment Model Technical Advisory Committee will meet on September 16, 2016.  The Committee will continue discussions about the process by which physician focused payment model proposals will be received and reviewed by the Committee in accordance with regulations implementing Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) physician payment reforms.

The Centers for Medicare & Medicaid Services (CMS) has announced proposals for three new “episode payment models” that, like the Comprehensive Care for Joint Replacement (CJR) model, would mandate provider participation in selected geographic areas. The episodes included in these payment models would address care for heart attacks, coronary artery bypass graft, and surgical hip/femur fracture treatment (excluding lower-extremity joint replacement). The performance period for these proposed episode payment models would begin July 1, 2017, giving hospitals and other providers a very short amount of time to prepare for these new payment methods. Comments are due October 3, 2016. Reed Smith is available to assist clients with preparation of comments or questions related to the proposed rule.
Continue Reading CMS Proposes Three New “Episode Payment Models” for Cardiac Care, Hip/Femur Fracture Cases, Plus Changes to CJR Model

On July 25, 2016, CMS announced ambitious, multi-pronged plans to expand mandatory Medicare coordinated care/bundled payment programs, promote the use of cardiac rehabilitation services, refine current Comprehensive Care for Joint Replacement Model (CJR) rules, and integrate bundled payment programs into the upcoming Medicare physician quality/payment framework. The proposed “Advancing Care Coordination through Episode Payment Model” rule is part of the Administration’s efforts to move the Medicare system away from fee-for-service (FFS) payments and towards alternative payment models that reward quality of care rather than volume of services.
Continue Reading CMS Unveils New Mandatory Medicare Bundled Payment Models for Cardiac & Hip Fracture Cases, Plus Proposed Refinements to CJR Program

CMS has published a final rule to allow organizations approved as “qualified entities” to confidentially share or sell analyses of Medicare and private-sector claims data to providers, employers, and other groups who can use the data to support improved care. CMS expects the rule to lead to “more transparency regarding provider and supplier performance and innovative uses of data that will result in improvements to the healthcare delivery system while still ensuring appropriate privacy and security protections for beneficiary-identifiable data.” As mandated by the Medicare Access and CHIP Reauthorization Act (MACRA), qualified entities will be required to combine the Medicare data with other claims data (such as private payer data) to produce reports on provider and supplier performance across multiple payers. The rule includes annual reporting requirements, along with privacy and security rules to protect beneficiary information, including protections for patient-identifiable data that are at least as stringent as what is required of covered entities and their business associates for protected health information (PHI) under HIPAA.
Continue Reading CMS Finalizes Plan to Expand Medicare/Private Claims Data Available for Care Improvement

MedPAC has released its June 2016 Report to the Congress on Medicare and the Health Care Delivery System. The report includes recommendations for a number of Medicare policy reforms and analyses of various health care market developments. Several chapters address Medicare drug policy, including a review of external factors that influence the prices Medicare pays for prescription drugs. With regard to Medicare Part B drug policy, MedPAC discusses potential modifications to Medicare Part B drug reimbursement, such as reducing dispensing and supplying fees, along with approaches to improving the quality and reducing the costs of oncology care (since more than half of Medicare Part B drug spending is associated with anticancer and related drugs). Likewise, MedPAC examines the Medicare Part D prescription drug program and offers recommendations for giving plan sponsors greater financial incentives and mechanisms to manage the benefits of high-cost enrollees; exclude manufacturer discounts on brand-name drugs from counting as enrollees’ true out-of-pocket spending; eliminate beneficiary cost sharing above the catastrophic cap; and increase financial incentives for low-income beneficiaries to use lower-cost drugs and biologicals.

MedPAC also discusses development of a unified Medicare payment system for post-acute care, including its unified prospective payment system (PPS) prototype that it believes accurately predicts resource needs for nearly all patient groups. MedPAC raises various implementation considerations, including the need to develop separate payment models for nontherapy ancillary services and the combination of routine and therapy services; adjustments to recognize lower costs in home health agencies compared to institutional settings; the need for outlier policies and labor cost adjustments; future adjustments to reward high-quality, efficient care; conforming regulatory reforms; and an appropriate transition period, among other policy provisions.

In addition, the report addresses:
Continue Reading MedPAC Issues Recommendations on Medicare Drug, Post-Acute Care, and Other Payment Policies

The House Ways and Means Committee has approved an amended version of H.R. 5273, the “Helping Hospitals Improve Patient Care Act of 2016.”  While most of the provisions address Medicare payment policies pertaining to hospitals (including long term care hospitals (LTCHs) and hospital outpatient departments), certain other reimbursement policies, including Medicare Advantage and physician payment…

CMS has published corrections to its November 16, 2015 Medicare physician fee schedule final rule with comment period for 2016, applicable beginning January 1, 2016. Among other things, CMS is correcting an omission of language restating the Consumer Assessment of Healthcare Providers and Systems (CAHPS) requirements that apply to groups of 100 or more eligible…

Recent Congressional hearings focusing on health policy topics include the following:

  • House Energy and Commerce Committee hearings on HHS cybersecurity responsibilities, Medicare and Medicaid program integrity, the Administration’s proposed Medicare Part B drug payment model, and patient-focused health insurance reforms.
  • House Ways and Means Committee hearings on implementation of the Medicare Access & CHIP Reauthorization

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The Centers for Medicare & Medicaid Services (CMS) has proposed regulations to implement major reforms of the Medicare physician fee schedule (MPFS) update framework that were mandated by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  As discussed in our client alert, MACRA repealed the longstanding sustainable growth rate (SGR) methodology for updating the MPFS. Instead, MACRA established a period of stable MPFS annual updates, after which MPFS updates will be made pursuant to either a new Merit-based Incentive Payment System (MIPS) or based on participation in qualified Alternative Payment Models (APMs). CMS’s proposed rule to implement the MIPS and APM reforms, which together CMS calls the “Quality Payment Program,” is lengthy (the advance version is almost 1000 pages) and very complex. The following is an overview of the major provisions of the rule.
Continue Reading CMS Proposes Implementation of MACRA Physician Payment Reforms

A number of recent Congressional hearings have focused on health policy topics, including the following:

  • A House Energy and Commerce Subcommittee on Health hearing on “Medicare Access and CHIP Reauthorization Act of 2015: Examining Physician Efforts to Prepare for Medicare Payment Reforms.”
  • A House Judiciary Constitution and Civil Justice Subcommittee hearing on oversight of the

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On April 19, 2016, the House Energy and Commerce Subcommittee on Health is holding a hearing entitled “Medicare Access and CHIP Reauthorization Act of 2015: Examining Physician Efforts to Prepare for Medicare Payment Reforms.”  The hearing will focus on major physician organizations’ investments in the development of alternative payment models, quality measures, and practice improvements.