RBMA Washington Insider - November 13, 2017
1. Last Week in Review
A big political week both inside and out of Washington saw a few statewide electoral victories for the Democratic party, while Republicans in Congress moved a step closer to passing tax reform legislation. On Tuesday, voters headed to the polls in several states for a series of off-year elections. In the most high-profile race, Ralph Northam defeated Ed Gillespie for the Virginia governorship by a nine-point margin, four points more than Hillary Clinton’s victory in the state last year. That fact has some political analysts viewing the results as an early indicator for next year’s midterm elections, particularly as exit polls suggest that voters viewed the Virginia and New Jersey races as a referendum on President Trump.
From a health policy perspective, Tuesday’s polls saw Maine vote for Medicaid expansion by referendum, although their Republican governor, Paul LePage, has vowed to resist implementation. Additionally, the Democratic sweep in Virginia may also lead to that state eventually deciding to expand Medicaid.
In Washington, following a contentious four-day markup, the House Ways and Means Committee advanced their version of tax reform legislation out of committee on Thursday on a 24-16 party line vote, setting up House floor consideration this week. The Senate shortly followed by introducing their own tax plan, which also focuses on cutting corporate and individual rates, but differs from the House version in significant ways.
The upcoming special election in Alabama took a significant turn last week after Republican nominee Roy Moore was accused of initiating a sexual encounter with a 14-year-old girl from when he was 32. President Trump, Senate Majority Leader Mitch McConnell (R-KY) and other GOP leaders called on the 70-year-old nominee, who denied the allegations that involved other teenagers between the ages of 16 and 18, to step aside if the accusations are true.
2. CBO Issues Revised Estimate Regarding Repeal of Individual Mandate
Last Wednesday the Congressional Budget Office (CBO) issued an updated estimate regarding cost savings associated with repealing the Affordable Care Act’s (ACA) individual mandate and the penalty that those who do not purchase health insurance currently must pay. CBO projected that repealing the individual mandate, by itself, would reduce the federal deficit by approximately $338 billion over the ten-year period 2018-2017 and increase the number of uninsured by four million in 2019 and 13 million in 2027. CBO notes that the updated estimates reflect revised projections of enrollment, premiums and other factors. CBO also estimated that nongroup insurance markets would “continue to be stable in almost all areas of the country” and average premiums in the nongroup market would increase by approximately ten percent in most years during the ten-year period.
CBO notes that the changes would occur mainly due to the fact that elimination of the mandate would result in: (1) healthier people being less likely to purchase health insurance, and (2) more Americans foregoing coverage due to higher projected premium increases. CBO states that the budgetary effects were measured relative to its summer 2017 baseline. In contrast, when the same policy was recently measured starting a year earlier and relative to CBO’s March 2016 baseline, CBO estimated that elimination of the individual mandate would reduce budget deficits by $416 billion between 2018 and 2026 and increase the number of uninsured by 16 million in 2026.
Despite the considerable scored savings, it remains unlikely that Republican leadership in the House or Senate will include the mandate repeal in current tax reform legislation. Nonetheless, a few GOP lawmakers have pushed to include the policy to help offset the cost of tax reform legislation, and possibility of including repeal of the individual mandate in the tax bill has not been entirely eliminated.
3. Imaging Stakeholders Prepare for 2018 State Legislative Season
While state legislative activities in 2017 are winding down, imaging advocates are gearing up their planning efforts for 2018. Legislatures in 46 states will meet in 2018 legislative sessions. Montana, Nevada, North Dakota and Texas are the only exceptions. Their legislatures will not convene in 2018. Fourteen states have begun to pre-file bills, and 17 more will be accepting proposals in November and December. California, Nebraska, North Carolina, Ohio, Idaho and Wisconsin do not allow legislation pre-filing. In these states, all bills are submitted only when their legislatures are in session.
Imaging stakeholders expect to see lots of activity during final two months of 2017 in advance of 2018 legislative sessions. States have an incentive to act quickly because pre-filing cuts down preparation time. Once the agenda schedules are finalized, deliberations can begin at the very start of the legislative session. Several pre-filed bills for 2018 already address hotly debated medical imaging issues:
- Florida HB 199. Related to balance billing and proposing to revise requirements for prior authorizations for health care benefits; provide requirements and procedures for insurers to specify order of medical procedure, course of treatment or prescription drugs used to treat insured's condition.
- Florida SB 164. Related to breast density reporting, to require facilities performing mammography to include certain information in a summary of the mammography report which must be provided to each patient.
- New Hampshire HB 1471. Related to telemedicine reimbursement parity.
4. CMS Administrator Verma Unveils ‘New Direction’ for Medicaid Program
Last Tuesday, at the 2017 Fall Conference of the National Association of Medicaid Directors (NAMD), Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma delivered a speech in which she unveiled a new vision for the Medicaid program, under which new policies will “encourage states to propose innovative Medicaid reforms, reduce federal regulatory burdens, increase efficiency, and promote transparency and accountability.”
Most notably, the CMS Administrator indicated that the agency intends to encourage and approve state requests to impose employment, education, or training requirements – what she called “community engagements” – on able-bodied, adult Medicaid beneficiaries. “Let me be clear to everyone in this room,” she announced, “We will approve proposals that promote community engagement activities.” Her carries imminent significance, given that at least six states currently have Section 1115 Medicaid waiver applications pending before the agency she heads that propose work requirements.
Administrator Verma also discussed several new policies and initiatives to achieve the Administration’s goals of greater flexibility for states. Administrator Verma pointed to revised content at Medicaid.gov intended to provide states with “a clearer indication of how their reform strategies might align with a core objective of the Medicaid program.” The new website content reflects a broader view of Section 1115 demonstrations, and is intended to signal the agency’s “willingness to work with state officials requesting flexibility.” Administrator Verma also announced that CMS is in the early stages of developing Medicaid and CHIP Scorecards, designed to promote greater transparency and accountability in the program by tracking and publishing state and federal Medicaid outcomes.
5. Healthcare.gov Signups Surge in First Four Days
The Trump administration announced Thursday that more than 600,000 individuals had enrolled for healthcare via the federal government’s Healthcare.gov website during the first four days of open enrollment. This is “roughly double” the number of individuals who signed up last year, according to a HHS official. There were about 150,000 sign-ups per day on average for the first four days this year, compared to 84,000 sign-ups per day for the first 12 days last year. There is no data for just the first four days of last year. It is reported that 130,000 individuals were new customers this year, while 460,000 were returning customers. The open enrollment period will end December 15th, roughly half the length of the open enrollment period last year.
Experts are treating the surge in enrollment with caution, as they warn the influx of signups could be caused by an early rush to beat the new deadline. Still, many supporters of the Affordable Care Act (ACA) are energized by the large enrollment, as analysts had feared the lack of federal spending on outreach and marketing under the Trump administration would gravely disrupt the exchanges. Analysts at Standard & Poor's had projected that up to 1.6 million fewer Americans would sign up for coverage through HealthCare.gov this year, down from 12.2 million enrollments last year. Also of concern was the administration’s decision to end cost-sharing reduction (CSR) payments to insurers, causing uncertainty that lead to higher premiums for most. An analysis by Avalere Health revealed that more than 8 in 10 ACA Exchange customers qualify for premium assistance, which means they’re largely protected from the big rate hikes, and the administration’s CSR decision inadvertently led to the creation of essentially free plans (due to hard-wired increases in premium subsidies) for low-income customers in nearly every county in the country.
6. Imaging Advocates Reassured About CDS Delay In MPFS Final Rule
After conducting a detailed review of the 2018 Medicare Physician Fee Schedule Final Rule, imaging advocates remain supportive of the Centers for Medicare and Medicaid Services’ (CMS’s) decision to delay starting the Medicare’s Congressionally mandated clinical decision support (CDS) program until January 1, 2020. In response to imaging stakeholders, CMS abandoned its proposal to use a complex series of G-codes and modifiers to report consultation of appropriate use criteria (AUC) for advanced diagnostic imaging services. Instead, CMS will develop a system that uses the unique consultation identifier produced by qualified clinical decision support mechanisms. Advocates believe these changes will lead to a more streamlined and less burdensome claims processing system.
In addition, CMS will continue to explore opportunities for stakeholder education and to address other suggestions and concerns raised during the proposed rule comment period. These include clarification on what will be expected during the one year “educational and operations testing period,” possible expansion of the significant hardship exceptions, clarification on who is authorized to perform the AUC consultation, and details about implementation of the statute’s physician outlier provision.
7. CMS Accepts Appeal for Higher MUE Values
Imaging and gynecology advocates have prevailed in their joint appeal to the Centers for Medicare & Medicaid Services (CMS) for higher Medically Unlikely Edit (MUE) values for two fetal interventional procedures involving ultrasound guidance. On Oct. 30, CMS announced it will revise its previous edit for the MUE values of CPT codes 59074 Fetal fluid drainage (e.g., vesicocentesis, thoracocentesis, paracentesis), including ultrasound guidance and 59076 Fetal shunt placement, including ultrasound guidance. As requested, the MUE value for these procedures will be increased from 1 to 2. The change will be implemented on Jan. 1, 2018, and will appear in the Medicaid National Correct Coding Initiative (NCCI) MUE files.
The MUE value is the maximum units of service that a provider may report under most circumstances for a single beneficiary on a single date of service. Payment claims for procedures involving more units than the MUE value are routinely denied initially. However, providers can gain payment by submitting an appeal with adequate documentation of medical necessity to substantiate the unusual circumstances. The appeal, filed on Sept. 27, asked CMS for an Medicaid MUE value 2 for CPT codes 59074 and 59076 to equal the Medicare MUE value of 2 for these procedures because the codes may be reported twice in the case of twin fetuses. In addition, a rare possibility exists for the performance of two, separate, medically necessary procedures, such as thoracentesis and paracentesis, on the same singleton fetus. In response to the successful appeal, CMS Medicaid will make payments for any denied claims, based on the MUE value of 2 for both codes. Payments will be retroactive to July 1, 2017, the date when this edit was developed. After July 1, 2017, any claims that were denied based on this edit may be resubmitted for payment.
8. CMS Offers New Quality Payment Program Year Two Resources
With Year two of the Quality Payment Program (QPP) approaching, CMS has moved its library of Quality Payment Program resources to CMS.gov. This will make it easier for clinicians to search and find information on the QPP. Clinicians will be able to search the library for QPP resources by title, topic or year. Resources include fact sheets, user guides, and other materials to help clinicians successfully participate in the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) in 2017. Other important resources are listed below:
- MIPS Data Validation Criteria: Details the criteria CMS will use to audit and validate measures and activities for the 2017 transition year of MIPS for the Quality, Advancing Care Information, and Improvement Activities performance categories.
- MIPS Scoring 101 Guide: Offers a deep-dive into scoring for the MIPS performance categories, and how the final score affects payment adjustments.
- MIPS Claims Data Submission Fact Sheet: Provides detailed information for clinicians who choose to submit 2017 MIPS data via Claims.
- Eligible Measure Applicability Toolkit: Contains information about the Eligible Measure Applicability (EMA) process, which assists clinicians in finding clinically-related measures available for them to submit based on the measure data they’ve chosen to report.
Learn more about the Quality Payment Program (QPP) Year two with the following free webinars offered by CMS:
- QPP Year Two Overview Webinar
November 14 1:00pm – 2:30pm ET: CMS policy experts provide an overview of the final requirements for the second year of the Quality Payment Program.
- Virtual Groups Train-the-Trainer
November 17 2:00pm – 3:00pm ET: CMS will provide an overview of Virtual Groups and the election process, and address questions from participants.
- QPP Year Two Final Rule Call
November 30 1:30pm – 3:00pm ET: Learn about the Quality Payment Program Year Two provisions in the final rule with comment and interim final rule with comment; participants should review the final rules prior to the call.
9. This Week in Congress
Tax reform will remain central to action in both chambers this week as Republican lawmakers hurry to finish a bill before the end of the calendar year. The House version of tax reform legislation is expected to hit the floor of the lower chamber this week after being approved by the House Ways and Means Committee on Thursday. While some Republican defections appear inevitable, the party’s leadership have been confident that the bill will pass before the end of the week. Meanwhile, the Senate Finance Committee is set to begin marking up its tax reform bill on today after releasing a summary document late last week. In addition to watching for Republican schisms, observers will be looking for any signals from moderate Democrats that they may be able to support a tax reform package if given some concessions.
While the House focuses on a tax reform vote, the Senate has teed up additional confirmation votes. Today, the chamber will vote to confirm Derek Kan as Under Secretary of Transportation and to invoke cloture on the nomination of Stephen Bradbury to be General Counsel at the Department of Transportation. Joseph Otting’s nomination to be Comptroller of the Currency is officially in the Senate queue after Majority Leader Mitch McConnell (R-KY) filed for cloture on the nomination on Friday.
10. Upcoming Events
- TBA – Senate Finance Markup: Tax Reform – The Senate Finance Committee is expected to mark up its version of tax reform legislation. Formal notice is forthcoming.
- 10:00am – Hearing: Opioid Crisis – The American Enterprise Institute hosts a briefing with House Energy and Commerce Committee Chairman Greg Walden (R-OR) to discuss the opioid crisis and Congress’ efforts to address it. Details here.
- 5:00pm – Politico Event: Emerging Leaders – Politico hosts its seventh annual Emerging Health Care Leaders event featuring remarks from congressional health policy staffers. Details here.
- 10:00am – Hearing: Healthy Communities – The Senate Committee on Health, Education, Labor, and Pensions (HELP) hosts a hearing, “Encouraging Healthy Communities: Perspective from the Surgeon General.” Details here.
- 9:00am-5:00pm – Hearing: Devices – The Food and Drug Administration (FDA) holds a hearing on a potential approach for certain device sponsors to seek marketing authorization for a device labeled for use with a drug that is already approved. Details here.
Additional Multi-Day Events
- Nov. 13-Nov. 14 – NAM: Workshop: Oncology – The National Academies of Medicine (NAM) hosts a workshop, “Establishing Effective Patient Navigation Programs in Oncology: A Workshop.” Details here.