AMDA’s Policy Successes in 2015 and Looking Forward to Pivotal 2016

December 18, 2015
Policy Snapshot

It is likely that 2015 will be remembered as a crucial year of policy implementation that will set the stage for the future of health care delivery. It began early last January with an announcement from Health and Human Services (HHS) Secretary Sylvia Burwell that left the fee-for-service as the sole reimbursement model in the dust and moved us with lighting speed into the future of health care delivery. HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. The announcement paved the way for a slew of legislative and regulatory changes that moved us closer to achieving these goals. As we write this at the end of 2015, that shift was dramatic - the 17 year old failed sustainable growth rate (SGR) formula is out, MACRA, MIPS, AMS, and the IMPACT Act are in. If you haven’t become familiar with the new dizzying array of acronyms, you will certainly know them by heart at the end of 2016. Of course, if such global changes in the health care system were not enough, the President also announced at the 2015 White House Conference on Aging that the original post-acute and long-term care (PALTC) regulations which were put in place in 1991 after the passage of OBRA ’87, were going to undergo a major revision.

Through it all, AMDA’s policy staff and its volunteer leaders stayed on top of all of the issues and achieved major milestones. Here are just a few highlights of what AMDA was able to achieve with all of your help:

  • Repeal of the SGR – AMDA was on the forefront working with both its physician specialty organization colleagues, consumer groups, and other stakeholders to finally repeal the flawed SGR formula.
  • Payment for Advanced Care Plan Codes – AMDA has long advocated that advance care planning and goals of care discussions should be a reimbursable service. AMDA was one of the key associations that put forward the effort and argued in front of Congress, the Centers for Medicare & Medicaid Services (CMS), and the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) to get this service reimbursed. After many challenges, two CPT codes 99497/99498 will be reimbursed starting January 1, 2016.
  • Removal of SNF POS 31 from ACO Attribution Methodology – early in 2014 AMDA formed a workgroup to better understand and advocate for an improved approach of patient attribution to ACOs. As a result of AMDA’s work with CMS and other stakeholders, in 2015 CMS finalized its proposal to remove SNF POS 31 from the ACO attribution models. It means that patients will now be attributed to their correct primary care providers who are responsible for their care.
  • Work on quality measure risk adjustment for cost measures – the same workgroup identified significant issues with risk-adjustment methodology used in the value-based payment modifier (VM). While the issue is complex, in short, AMDA’s analysis showed that physicians practicing in PALTC settings were viewed as “high cost” providers because of their high cost in comparison to other general primary care providers. While the issue remains unresolved, CMS acknowledged in its rulemaking that there needs to be a solution to this issue.
  • Participation in White House Conference on Aging – AMDA was a key participant in a series of regional events as well as the big national even in Washington D.C. AMDA President Naushira Pandya, MD, CMD, represented AMDA on a panel at a regional meeting in Tampa, FL and was invited to participate in the main event at the White House. AMDA worked closely with the event director Nora Super to advocate for more and better trained geriatric workforce as well as a number of other issues. AMDA’s message was well received at the events and by the press covering the conference.
  • Participation on national quality committees – in 2015 AMDA members are in the national spotlight. This year we have successfully nominated a record number of AMDA members to key national committees and workgroups that will be developing quality measures and reporting standards in future health care payment models. AMDA is a key participant in a variety of CMS Expert Technical Panels that are working on developing measures for the IMPACT Act. Likewise, AMDA was appointed to serve on the National Quality Forum’s PALTC workgroup as well as a variety of other committees that are working on endorsement of a robust quality measure portfolio.

While the list of accomplishments in 2015 is impressive, it only sets the stage for more work to be done in 2016 which promises to be a pivotal year for implementing many reforms scheduled to take full effect in near future. Already, AMDA submitted comments to CMS on the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA), which was enacted on April 16, 2015. The Act repealed the SGR, provided annual 0.5% updates through 2019 and a frozen physician fee schedule conversion factor for the next six years. AMDA’s comments focused on the future of the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) which will be the new way providers will get incentive payments and in some cases of poor performers, payment reductions. See table below for implementation schedule of the law. Click here to view an overview and a discussion of all these changes from an Open Policy Forum held earlier this year.

MIPS Payment Adjustment Factors

  Maximum Positive Adjustment Before Budget Neutrality Scaling Factor Maximum Negative Adjustment Factor Maximum Positive Adjustment After Budget Neutrality Scaling Factor
CY 2019 4% -4% 12%
CY 2020 5% -5% 15%
CY 2021 7% -7% 21%
CY 2022 and beyond 9% -9% 27%

The IMPACT Act was also a significant piece of legislation that passed in late 2014 but was implemented throughout 2015. The Act requires post-acute providers (facilities) to report standardized assessment data and use that data to explore and build new payment prototypes for future post-acute payment reforms.

CMS is set to consider the large volume of comments the agency received on its proposals to revise the PALTC Requirements of Participation. AMDA carefully and thoughtfully commented on each of the proposed updates. Amongst the many proposals AMDA focused on the face-to-face practitioner visits before a patient is sent to the hospital, 48 hours limit on prn psychotropic, definition of psychotropic drugs expanded to include opioids, quality assurance and performance improvement (QAPI) regulations, IDT process to include nursing assistant and concerted efforts to include resident and/or family, and beefs up PASRR requirement including notification of state agency every time there is a change.

Finally, CMS is set to evaluate utilization of the array of new codes implemented over the last several years. The Transitional Care Management (99495, 99496), Chronic Care Management (99490) and Advance Care Planning (99497-99498) are all now billable. It’s possible that more codes that expand on these services will be developed.

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