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EPtalk by Dr. Jayne 9/15/16

September 15, 2016 Dr. Jayne No Comments

I was reminded today that this year marks the 20th anniversary of the Health Insurance Portability and Accountability Act of 1996, affectionately known as HIPAA (or HIPPA, as the case often is). As much as we lamented its beginning, most of us had no idea how much more regulation we would see in the healthcare space during the subsequent decades. Physicians and other healthcare providers are now more regulated than they have ever been, which has contributed significantly to physician burnout and early retirement in many communities.

Regulations are often nested within other policy and regulatory documents. A recent example of this is a requirement in the proposed 2017 Medicare fee schedule that would require surgeons and other procedural physicians to report a series of G codes during the postoperative period. The codes vary based on place of service, patient complexity, and time. They don’t match cleanly with existing bundled services. The fee schedule also proposes changes to the quality measures used for Accountable Care Organizations, which also met with resistance.

Sometimes CMS announces plans which benefit physicians, which feels like a rarity. The recent announcement of a “pick your pace” approach to MACRA implementation was welcomed due to the apparent flexibility of the approach. There are a few options for MIPS reporting in 2017:

  • Providers can simply test their ability to report data, doing so at least once at some point during the year. Completion of testing allows providers to avoid penalties and ensures that systems are functioning prior to greater participation in subsequent years.
  • Providers can also consider reporting for part of the calendar year. However, they must report performance in all three Composite Performance Score (CPS) categories. This approach could result in a small bonus in 2019.
  • Providers can report the full calendar year (again in all three categories) to achieve what CMS describes as a “modest” bonus in 2019.
  • Providers participating in certain Advanced Alternative Payment Models can qualify for a five percent bonus.

Selecting the third option will depend on the ability of vendors to quickly become compliant with the requirements of the final rule, which is expected to be released by early November. This means that they have very little time to achieve software readiness and upgrade thousands of providers. Depending on vendor resources and how much prep work has been done in anticipation of the release of the final rule, full-year reporting may be little more than a pipe dream.

For those of us who live and breathe this on a daily basis, having some flexibility in reporting seems refreshing. But for the large numbers of physicians and practices who have no idea what MACRA even is, let alone that these regulations are coming, the flexibility won’t be very comforting.

I recently received a blast letter from the Drug Enforcement Administration letting me know I would have to upgrade my browser in order to access DEA resources and renew my registration. That’s insignificant to many physicians, yet the DEA felt it was important enough to mail paper correspondence to every registered physician across the country. MACRA and the associated penalties and incentives are a big deal. Where is the letter to all Medicare providers? CMS is expecting physicians to follow blogs and tweets and webcasts that many physicians don’t even know exist.

I’m not absolving physicians from being responsible for what is going on in the world around them, but merely commenting on the reality of many physicians out there, which has also been reflected in various surveys and articles. Ultimately if a physician is going to contract with a payer, he or she is responsible for knowing the rules, but it certainly could be easier.

What’s also not easy is figuring out how to actually achieve savings under Alternative Payment Models. Recently CMS released performance data for 2015. The numbers show that of 404 Medicare ACOs, only 125 of them qualified for shared savings. Of the 392 Shared Savings Program ACOs, only 119 qualified for shared savings. Participation in Pioneer ACOs continues to shrink, with only 12 remaining.

I don’t think those statistics make Alternative Payment Models look appealing to the average physician. Of course the “appeal” is different for providers employed by hospitals and large health systems who are simply forced to participate. Those that weren’t successful based on the metrics are still doing the extra work required of ACO members but just not getting the shared savings payments at the end.

I do feel that CMS is listening and trying to respond. Recently they changed the rules for the Medicare Chronic Care Management services code to remove a requirement that providers have 24/7 access to patient records. The code allows providers to bill for coordination of care for patients who have chronic conditions. However, I’m not sure what kind of burden the 24/7 rule really was.

The bigger barrier in my experience is the fact that patients have to pay a portion of the charge, and many don’t see the benefit because the services performed on their behalf are often done behind the scenes – phone calls to consultants, review of personal health log data, etc. There’s also a process required to obtain patient consent for participation which adds to challenges in adopting the service. I find it funny that people who will pay for a maintenance/protection program for their phone will balk at paying for something similar to help safeguard their health.

I’m mentoring some medical students and several are out on ambulatory clinical clerkships, working with practicing community physicians. They always have questions about how regulations are going to impact them in practice. Sometimes I have answers and sometimes there are no good answers. What they see, however, is definitely driving them away from primary care, where it seems that providers feel a greater burden. We’re getting thousands of new Medicare beneficiaries each day, so the need for processes and policies is real in order to successfully manage the demands. I think many of us wish that there was just a better way.

What are you doing to celebrate the 20th anniversary of HIPAA? Email me.

Email Dr. Jayne.

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