National Health Law Program: Analysis of ACA Section 1557 Final Rule

This is the National Health Law Program’s initial analysis of the final rule implementing section 1557 of the Affordable Care Act (ACA) prohibiting discrimination in federally funded health programs and services on the basis of race, color, national origin, age, sex, and disability. The analysis highlights the broad application of the ACA’s prohibition against discrimination, and the key additions of sex and disability as protected classes under the law.

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Advancing Equity, Language Access, Language Access: Standards, Lesbian, Gay, Bisexual and Transgender Health | Leave a comment

U.S. Department of Health and Human Services Office of Civil Rights: Final Rule Prohibiting Discrimination Under Affordable Care Act

The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) has issued its final rule implementing Section 1557 of the Affordable Care Act prohibiting discrimination on the basis of race, color, national origin, sex, age, and disability. Discrimination based on sex includes discrimination based on pregnancy, gender identity, and sex stereotyping. Discrimination based on national origin includes discrimination based on limited English proficiency.

While the final rule does not resolve whether discrimination on the basis of an individual’s sexual orientation status alone is a form of sex discrimination under Section 1557, the rule makes clear that OCR will evaluate complaints that allege sex discrimination related to an individual’s sexual orientation to determine if they involve the sorts of stereotyping that can be addressed under 1557. HHS supports prohibiting sexual orientation discrimination as a matter of policy and will continue to monitor legal developments on this issue.

The final rule also states that where application of any requirement of the rule would violate applicable federal statutes protecting religious freedom and conscience, that application will not be required.

Link to Original Source

 

Posted in Health Care Reform, Health Care Reform: Advancing Equity, Language Access, Language Access: Standards, Lesbian, Gay, Bisexual and Transgender Health | Leave a comment

Centers for Medicare and Medicaid Services: MACRA Proposed Rule Fact Sheet about Small Practices

The Centers for Medicare and Medicaid Services (CMS) has published this fact sheet describing how small group physician practices (defined as practices with 15 or fewer physicians) and practices in rural or health professional shortage areas will be impacted and accommodated under CMS’ proposed rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA).

For example, under the proposed rule, clinicians or groups who have less than or equal to $10,000 in Medicare charges AND less than or equal to 100 Medicare patients are excluded from any payment adjustment or penalty under the MACRA Merit Incentive Payment System (MIPS). In addition, if there are insufficient measures and activities applicable and available in any MIPS performance category, then the category would not be included in the MIPS score for that clinician or group (and the weight of other MIPS performance categories would be adjusted to make up the difference in the MIPS score). CMS also is inviting public comment on how solo and small group practices may join “virtual groups” and combine their MIPS reporting; such virtual group reporting would not be implemented until the second payment year, or fiscal year 2020.

MACRA also authorized up to $100 million over five years to provide technical assistance to small practices; on April 13, CMS quietly began the process to issue a request for proposals (RFP) for contractors to provide that technical assistance, but CMS has yet to release any details of the RFP except that the successful technical assistance contractors are expected to begin their work in November 2016.

The fact sheet also references CMS-funded technical assistance already in place through its Transforming Clinical Practice Initiative, which was launched in September 2015, and the ongoing payment reform developmental work being conducted by public and private stakeholders through the Health Care Payment Learning and Action Network.

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement | Leave a comment

MACRA Physician-Focused Payment Model Technical Advisory Committee Issues Draft Proposal Review Process

The Physician-Focused Payment Model Technical Advisory Committee established by the Medicare Access and CHIP Reauthorization Act (MACRA) has issued a draft Proposal Review Process to review and recommend “physician-focused” Alternative Payment Models (APMs) for implementation through MACRA. The legislation established this Technical Advisory Committee of external subject matter experts to review and recommend APMs beyond what might be considered and recognized directly by the Centers for Medicare and Medicaid Services (CMS). The Committee is staffed by the Office of the Assistant Secretary for Planning and Evaluation (ASPE). With CMS’ publication of its proposed rule implementing MACRA, the role of this Technical Advisory Committee has received more attention.

Under the draft Proposal Review Process, the Technical Advisory Committee would accept ongoing submission of APM proposals (with no fixed deadlines or submission cycles). Proposals would undergo an ASPE staff review for completeness, then a preliminary review and scoring by 2-3 committee members, and finally, a review by the full committee. The full committee would make a recommendation about the proposal to the Secretary of Health and Human Services, with a minority report if needed. Pubic comment would be invited for proposals reviewed by the full committee. Technical assistance would be offered by ASPE staff for incomplete proposals and proposals with technical deficiencies. The draft Proposal Review Process does not address the criteria for defining APMs since those are included in the MACRA statute, and further described in CMS’ proposed rule.

The Technical Advisory Committee discussed the draft Proposal Review Process and heard public comments about it at its meeting on May 4, 2016. Additional public comments may be submitted to the committee until May 13, 2016; comments may be sent by email to <PTAC@hhs.gov>.

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Payment Reform | Leave a comment

Centers for Medicare and Medicaid Services: Additional Resources on MACRA Proposed Rule

The Centers for Medicare and Medicaid Services (CMS) has made available two additional resources about its proposed rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA).  The first resource is a set of slides describing the proposed rule.

Link to Original Source

Then second resource is a slide deck with more specific information about the proposed Merit Incentive Payment System (MIPS) that most Medicare physicians will be using to seek additional bonus payments beginning in 2019.

Link to Original Source

CMS also is conducting a series of webinars about the proposed rule to prepare for the public comment deadline of June 27, 2016.

Posted in Health Care Reform, Health Care Reform: Accountable Care Organizations, Health Care Reform: Medical Homes, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement, Health Information Technology, Health Information Technology: Meaningful Use | Leave a comment

Centers for Medicare and Medicaid Services: List of Alternative Payment Models (APMs) under MACRA Proposed Rule

Buried deep (on pages 501-502) in the 900+ page pre-publication version of the Centers for Medicare and Medicaid Services (CMS) proposed rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA) is Table 32, which lists current Alternative Payment Models (APMs) and whether they would meet the criteria for qualifying APMs and Advanced APMs in the MACRA proposed rule. Interestingly, none of CMS’ Bundled Payment for Care Improvement Models 2-4, nor its Comprehensive Care for Joint Replacement initiative, would qualify as a MACRA APM.  And its Medicare Shared Savings Program Accountable Care Organizations Track One (with no down-side risk) would not qualify as an Advanced APM under MACRA.

CMS is inviting comments on this list before June 27, 2016.

Table 32 Proposed APMs Part 1

Table 32 Proposed APMs Part 2Link to Original Source

Posted in Health Care Reform, Health Care Reform: Accountable Care Organizations, Health Care Reform: Medical Homes, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement | Leave a comment

Community Catalyst: Consumer Policy Platform for Health System Transformation

Community Catalyst has published this policy platform for health system transformation from a health consumer perspective. When using the framework of the “triple aim”, consumers should be asking:

  • whether “better care” focuses on improving care for people with multiple chronic conditions and disabilities who account for the bulk of our national health care spending and who are often poorly served, and low-income people, racial and ethnic minorities and other marginalized populations
  • whether “better health” includes redirecting wasted resources in an inefficient medical care system to improve the social and economic conditions that generate a lot of acute and chronic health spending
  • whether “better value” addresses those features of the U.S. health care financing and delivery system that inflate our spending relative to other advanced industrial democracies but fail to improve clinical outcomes.

The policy platform includes six components:

  1. Structures for meaningful consumer engagement to ensure that people have a voice in policy decisions, the health care organizations that serve them and their own health care, including advisory councils and engagement of patients as part of clinical care.
  2. Payment arrangements that incentivize people-centered health care by paying providers for achieving the health outcomes that matter most, ensuring that providers are appropriately compensated for the care of complex patients, and reducing patient barriers to accessing needed care.
  3. Resources for community and population health in order to address the social and economic factors affecting the health of people in their communities, including the use of community benefit programs to reflect and target community needs and priorities, the improved alignment of community resources, an increased investment in prevention, and robust evaluation of population health outcomes.
  4. Consumer protection through the application of strong safeguards including independent and effective ombudsman programs,  consumer-centric quality measures, transparency, and consumer choice.
  5. Person-centered culture of care through the adoption of care models and best practices that meet the specific goals, preferences and needs of the population being served, including at the end of life, coordinated care, and integration of physical health, behavioral health and community supports and services.
  6. Health equity for underserved populations in all health system transformation efforts,  expanding the collection and reporting of data on disparities, ensuring that care improvement efforts specifically address health disparities, and promoting a culturally competent workforce, including the use of community health workers.

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement, Patient-Centeredness | Leave a comment

Centers for Medicare and Medicaid Services: Fact Sheet on MACRA Proposed Regulations

The Centers for Medicare and Medicaid Services has published this useful summary of its proposed rule implementing the Medicare Access and CHIP Reauthorization Act (MACRA):

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Accountable Care Organizations, Health Care Reform: Medical Homes, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement, Health Information Technology, Health Information Technology: Meaningful Use | Leave a comment

Centers for Medicare and Medicaid Services: Proposed Rule to Implement Medicare Access and CHIP Reauthorization Act (MACRA)

The Centers for Medicare and Medicaid Services (CMS) has published its much-anticipated proposed rule to implement the Medicare Access and Childrens’ Health Insurance Program (CHIP) Reauthorization Act (MACRA), which replaces the Sustainable Growth Rate formula for how fee-for-service or traditional Medicare pays physicians and other clinicians. After annual increases of 0.5% this year through 2019, clinicians will only receive increased Medicare payments through either a Merit Incentive Payment System (MIPS) or through participation in Advanced Alternative Payment Models (APMs). Medicare clinicians meeting the MIPS requirements would receive an additional 4 percent incentive payment beginning in 2019, increasing to 9 percent by 2022.  However, for those Medicare physicians who do not meet the new MIPS requirements, MACRA would penalize them up to the same 9 percent.  Medicare clinicians meeting the Advanced APM requirements would not be eligible for the MIPS incentives (nor subject to any penalties) and receive an additional 5 percent annual incentive payment beginning in 2019. CMS is calling the new payment mechanisms its Quality Payment Program (MACRA QPP).

The MIPS will combine and replace the existing Physician Quality Reporting System, Physician Value-Based Payment Modifier, and Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals. Under the proposed rule, the MIPS will include payments for:

  • Quality (50 percent of total score in year 1): For this category, Medicare clinicians would choose to report six measures from among a range of options that accommodate differences among specialties and practices; the final list of measures would be published by November 1 of the preceding year
  • Advancing Care Information (25 percent of total score in year 1): For this category, clinicians would choose to report customizable measures that reflect how they use technology in their day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing reporting program, this category would not require all-or-nothing EHR measurement or redundant quality reporting.
  • Clinical Practice Improvement Activities (CIPAs) (15 percent of total score in year 1): This category would reward clinical practice improvements, such as activities focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities (performed for a minimum of 90 days) that match their practices’ goals from a list of more than 90 options (an “inventory” that includes achieving health equity, integrated behavioral and mental health, and emergency preparedness and response). There would be no minimum number of CIPAs required in year 1.
  • Cost (10 percent of total score in year 1): For this category, the score would be based on Medicare claims using two measures: total per costs capita for all attributed beneficiaries and Medicare spending per beneficiary; there would be no reporting requirements for clinicians. This category would use 40 episode-specific measures to account for differences among specialties.

Among the most significant of the changes proposed by the rule is a change to the Medicare EHR Incentive Program. Rather than implementing Stage 3 requirements (currently scheduled for implementation beginning in 2017), MIPS’ Advancing Care Information requirements would:

  • Align with the Office of the National Coordinator for Health Information Technology’s 2015 Edition Health IT Certification Criteria
  • Simplify reporting by no longer requiring all-or-nothing EHR measurement or quality reporting, but revert to a full year reporting requirement rather than a 90-day reporting period
  • Reduce the number of quality measures to an all-time low of 11 measures, down from 18 measures; no longer require reporting on the Clinical Decision Support and the Computerized Provider Order Entry measures
  • Allow physicians and other clinicians to choose to select the measures that reflect how health IT best suits their day-to-day practice
  • Emphasize interoperability, information exchange, and security measures; and promote use of APIs (application program interfaces, or third party programs) that allow patients to access to their health information
  • Exempt certain physicians from reporting when EHR technology is less applicable to their practice, and allow physicians to report as a group.
  • Apply these Advancing Care Information requirements to Medicare clinicians (nurse practitioners, physician assistants, clinical nurse specialists, etc.) who have not been eligible to participate in the Medicare EHR Incentive Program for reporting purposes in year 1 in order to assess how the requirements would be applied in future years

There would not be a parallel change to Stage 3 requirements for eligible providers through the Medicaid EHR incentive program (which continues for some Medicaid providers through 2021), nor to Stage 3 requirements for hospitals under either the Medicare or Medicaid EHR Incentive Programs.

The rule proposes that MIPS payment adjustments for 2019 (year 1 of implementation) be calculated using 2017 as the performance year, but payment adjustments be calculated using one’s 2018 payment history.  According, the implementation of MACRA would essentially begin in just eight months, on January 1, 2017. The proposed rule notes that the Assistant Secretary for Planning and Evaluation is conducting studies on the issue of risk adjustment for socioeconomic status on quality measures and resource use, but does not expect to make recommendations until October 2016. Given these timelines, it is unlikely that such risk adjustment will be included in the proposed first performance year.  Quality measure performance data for Medicare eligible clinicians participating in MIPS would become publicly available on CMS’ Physician Compare website.

In the fiscal impact section of the proposed rule, CMS estimates that between 687,000 and 746,000 Medicare clinicians will participate in MIPS in 2019, and that half would receive bonus payments totaling $833 million, while the other half would receive penalties totaling the same amount. However, CMS estimates that solo practitioners would be penalized $300 million and only receive $105 million in bonus payments, while clinicians in groups of 100 or more would receive $529 million in bonus payments and only $57 million in penalties.

Under the proposed rule, Advanced APMs will include Medicare Shared Savings Program Accountable Care Organizations (ACOs)(Tracks Two and Three, with downside risk), Next Generation ACOs, some CMS bundled payment programs, patient-centered medical homes, and the recently announced Comprehensive Primary Care Plus initiative. While most of these programs are funded by or supported by CMS, the proposed rule includes a definition of patient-centered medical homes as one recognized by a national quality organization (National Committee for Quality Assurance, Joint Commission, Accreditation Association for Ambulatory Health Care, or URAC) or a state Medicaid program. Other Payer Advanced APMs also will be recognized (through Medicaid, commercial, or all-payer models) if they meet detailed criteria, including use of certified health IT,  payments tied to MIPS quality measures, and financial risk sharing.

Medicare physicians and clinicians, called qualifying participants (QPs), would be eligible for incentive payments if 25 percent or more of their Medicare payments are paid through an Advanced APM, or 20 percent or more of one’s patients are Medicare beneficiaries. These percentage thresholds will increase over time. CMS estimates that between 30,658 and 90,000 qualifying participants would receive between $146 million and $429 million in APM incentive payments in 2019.

The proposed rule does not describe how technical assistance will be made available to Medicare clinicians as required by MACRA, stating that regulatory guidance on that topic will be issued separately.

Comments on the proposed rule are due by June 27, 2016.

Link to Original Source

CMS also has created a video explaining MACRA:

Posted in Health Care Reform, Health Care Reform: Accountable Care Organizations, Health Care Reform: Medical Homes, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement, Health Information Technology, Health Information Technology: Meaningful Use | Leave a comment

Centers for Medicare and Medicaid Services: Final Rule for Managed Care in Medicaid and Children’s Health Insurance Program

The Centers for Medicare and Medicaid Services (CMS) has published a final rule, updating requirements for managed care plans funded by Medicaid and the Children’s Health Insurance Program.  The updated requirements are aligned with requirements enacted by the Affordable Care Act that are applicable to the federally-operated and state health insurance marketplaces.  In many of these marketplaces, Medicaid managed care plans are available among the options that health care consumers can choose from.  The updated requirements also are aligned with CMS’ drive towards health care delivery system reform.

Link to Original Source

The final rule will be published in the Federal Register on June 7, 2016.

CMS has published several fact sheets about the final rule, including this fact sheet about strengthening the consumer experience:

Link to Original Source

This fact sheet describes the alignment with Medicare Advantage and private, commercial health coverage:

Link to Original Source

And this fact sheet highlights how the final rule supports state efforts to advance health care delivery system reform:

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Advancing Equity, Language Access, Language Access: Standards | Leave a comment