CMS Releases the Calendar Year 2020 Final Rule for the Physician Fee Schedule and Quality Payment Program

On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the calendar year 2020 Physician Fee Schedule (PFS) and Quality Payment Program (QPP). The final rule for the PFS updates the conversion factor for the coming year and makes several other changes to the Fee Schedule. The PFS conversion factor for calendar year 2020 is $36.09 a $0.05 increase from 2019.

CMS finalized changes to evaluation and management (E/M) services. Most notable, CMS will retain 5 levels of coding for established patients and reduce the number of levels to 4 for new patients. CMS has also finalized several provisions related to substance use disorder treatment, including implementing aspects of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act).

There are several notable policy updates that CMS finalized for the upcoming QPP performance period. Among these are new performance thresholds. For performance period 2020, CMS has finalized a performance threshold of 45 points and an additional threshold of 85 points for exceptional performance. For performance year 2021, these figures will be 60 and 85 points, respectively. The performance category weights remain unchanged from 2019 at 45% for quality, 15% for cost, 25% for promoting interoperability, and 15% for improvement activities. CMS also proposed the MIPS Value Pathways (MVP) in the 2020 proposed rule. The MVP framework would go into effect during performance year 2021 of MIPS and aims to reduce burden, improve value, and better inform patients when they select a clinician. CMS finalized a modified proposal to define MVPs as a subset of measures and activities established through rulemaking.

The fact sheet for the final PFS rule can be found here. The fact sheet for the final QPP can be found here. AMGA's press release on the final rule can be found here. – By Emma Achola

CONNECT for Health Act of 2019 Introduced in Congress

On Oct. 30, Senators Brian Schatz (D-HI), Roger Wicker (R-MS), Ben Cardin (D-MD), John Thune (R-SD), Mark Warner (D-VA), and Cindy Hyde-Smith (R-MS) introduced the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019. The AMGA-endorsed bipartisan legislation would address several gaps in Medicare’s current telehealth policy by providing the Secretary of Health and Human Services with the authority to waive telehealth restrictions when necessary; removing geographic and originating site restrictions for services like mental health and emergency medical care; allowing rural health clinics and other community-based healthcare centers to provide telehealth services; and requiring a study to explore more ways to expand telehealth services so that more people can access healthcare services in their own homes. Companion legislation has been introduced in the House of Representatives by Representatives Mike Thompson (D-CA), Peter Welch (D-Vt.), David Schweikert (R-AZ), and Bill Johnson (R-OH). – Lauren N. Lattany, M.P.S.

Upcoming Webinars on Medicare Fee Schedule and Hospital OPP System

AMGA will host webinars in the coming weeks on the following:

• Overview of the Calendar Year 2020 Medicare Physician Fee Schedule and Quality Payment Program Final Rule - November 14, 2 p.m. Register
• Overview of the Calendar Year 2020 Hospital Outpatient Prospective Payment System (OPPS) Final Rule - November 21, 2 p.m. Register

Registration is complimentary for AMGA members.

CMS Releases the Calendar Year 2020 Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule

The Centers for Medicare & Medicaid Services (CMS) on Nov. 1 released the final rule for the calendar year 2020 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The final rule with comment period updates payments made under the OPPS and ASC payment system for the coming year and finalizes other provisions, including site neutrality and 340B payments. For the calendar year 2020, CMS is finalizing a 2.6% update for both OPPS payment rates and ASC payment rates. The update is based on the 3% market basket increase minus 0.4% for multi-factor productivity.

CMS also expressed its intent to continue the two-year phase-in of site neutral payments for clinic visits furnished in the off-campus hospital outpatient department (OPD). Despite being struck down by the United States District Court for the District of Columbia in September, CMS states “we do not believe it is appropriate at this time to make a change to the second year of the two-year phase-in of the clinic visit policy. The government has appeal rights, and is still evaluating the rulings and considering, at the time of this writing, whether to appeal from the final judgement.” CMS estimates that site neutral payments will save beneficiaries an average of $14 with each visit to an off-campus hospital OPD, by reducing their cost sharing to $9 per visit. Additionally, the government and taxpayers are expected to save $800 million for 2020.

CMS is also finalizing its proposal to continue to pay for 340B drugs at average sales price minus 22.5%. CMS acknowledges the court ruling earlier this year for the 340B program and states the agency is currently appealing the decision. They also solicited comments, which are summarized in the final rule, on ways to remedy the issue for calendar year 2018 and 2019 in the event of an unfavorable decision. The proposed rule from this summer included provisions that would require hospitals to post the prices they negotiate with payers for standard services and. The agency did not include these provisions in the final rule and says a separate rule on price transparency is forthcoming.

The fact sheet for the final rule can be found here. – By Emma Achola

AMGA Joins Substance Use Disorder SAMHSA Comment Letter 

On Oct. 25, AMGA joined a comment letter to the Substance Abuse and Mental Health Services Administration (SAMHSA) on 42 CFR Part 2. In the comments, AMGA and other members from the Partnership to Amend 42 CFR Part 2 Coalition, advocated for aligning 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA). A longstanding AMGA priority, the comments outlined specific recommendations to the SAMHSA rule that would allow appropriate access to patient information essential for providing whole person care while protecting patient privacy.

In the recommendations, the coalition requested clarification on proposed changes to non Part 2 providers’ patient records, consent requirements, and audit and evaluation and further requested that care coordination and case management be included under the definition of “health care operations.”

Comments also called for protecting Substance Use Disorder records, and aligning Part 2 with HIPAA for treatment, payment and health care operations. The comment letter can be found here. – Sarah Skirmont

CMS Releases the Calendar Year 2020 Home Health Prospective Payment System Final Rule

On Oct. 31, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for the calendar year 2020 home health prospective payment system (PPS). In addition to finalizing payment updates for the home health PPS, the final rule modifies payment regulations pertaining to the content of the home health plan of care, finalizes policies related to the split percentage payment approach, includes final policies related to the implementation of the permanent home infusion therapy benefit, and seeks comments on options to enhance future efforts to improve coverage for eligible home infusion therapy drugs.

For calendar year 2020, CMS estimates that payments to home health agencies will increase by 1.3% or $250 million. CMS is also implementing the Patient-Driven Groupings Model. This model, legislated by the Balance Budget Act of 2018, is an alternative case-mix adjusted payment methodology with a 30-day unit of payment. Additionally, CMS finalized payment policies related to the home infusion therapy benefit that is set to begin in calendar year 2021. CMS will group home infusion drugs into three payment categories and then adjust the payments for geography. The fact sheet for the final rule can be found here . – Emma Achola

CMS Releases the Calendar Year 2020 ESRD Prospective Payment System Final Rule

On Oct. 31, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for the calendar year 2020 end-stage renal disease prospective payment system (ESRD PPS). In addition to updating payments made under the ESRD PPS, the rule also finalizes updates to the acute kidney injury (AKI) dialysis payment rate and changes to the ESRD Quality Incentive Program (QIP).

For calendar year 2020, CMS has finalized a $4.06 increase to the ESRD PPS base payment rate, increasing it from $235.27 to $239.33. The base payment rate for the AKI dialysis payment rate is also $239.33. CMS also finalized updates to the outlier payment policy, updating the fixed-dollar loss (FDL) amounts and the Medicare Allowable Payment (MAP) amount for adult and pediatric patients. The FDL amount for pediatric cases decreased to $41.04, while the MAP amount decreased to $32.32. These figures for adult patients were $48.33 and $35.78, respectively.

CMS also finalized several changes to the quality reporting program for dialysis facilities, also known as the ESRD QIP. These changes included an updated scoring methodology for the National Healthcare Safety Network Dialysis Event reporting measure and a conversion of the Standardized Transfusion Ratio measure to a pay-for-reporting measure.

The rule also addresses changes to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) fee schedule. The fact sheet for the final rule can be found here. – Emma Achola 

CMS Announces the Fiscal Year 2020 Hospital Value-Based Purchasing Program Results

The Centers for Medicare & Medicaid Services (CMS) recently released the fiscal year 2020 results for the Hospital Value-Based Purchasing (VBP) Program. The results show that more hospitals will receive a positive adjustment (1,500 hospitals will receive higher payments) than will receive a negative adjustment. The average net payment adjustment is 0.16%. The highest performing hospital will see a 2.93% net increase in payments, while the lowest performing will receive a -1.72% net decrease in payments. CMS estimates that for fiscal year 2020, $1.9 billion will be available for value-based incentive payments. The Hospital VBP is one of four CMS quality reporting programs that aim to tie Medicare payments under the inpatient prospective payment system to the quality of care delivered.

The CMS fact sheet can be found here. – Emma Achola

Senate HELP Committee Advances Bipartisan Public Health Bills

Last week, the Senate Committee on Health, Education, Labor, and Pensions (HELP) held a markup to advance eight bipartisan public health bills addressing tick-borne diseases, respite care, nurse training, physical education, unexpected infant and childhood deaths, maternal health, public health emergencies, and over-the-counter (OTC) drug regulation. The committee adopted the following legislation by voice votes:

• S. 1657, the Ticks: Identify, Control, and Knockout (TICK) Act – to provide funding to address Lyme disease and other tick- and vector-borne diseases and disorders
• S. 2619, the Healthy Start Reauthorization Act – to reauthorize the Healthy Start Program to improve maternal health and reduce infant mortality
• S. 1399, the Title VIII Nursing Workforce Reauthorization Act – to revise and extend nursing workforce development programs
• S. 995, the Lifespan Respite Care Reauthorization Act – to reauthorize Public Health Service Act lifespan respite care programs
• S. 1130, the Scarlett’s Sunshine on Sudden Unexpected Death Act – to establish a program enhancing data, reporting and funding to address sudden unexpected infant and childhood deaths
• S. 1608, the Promoting Physical Activity for Americans Act – to require the Department of Health and Human Services (HHS) to issue and update physical activity recommendations
• S. 2629, the United States Public Health Service Modernization Act – to establish a Ready Reserve Corps in situations of public health and national emergencies
• S. 2740, the Over-the-Counter Monograph Safety, Innovation, and Reform Act – to clarify the regulatory framework under the Food, Drug, and Cosmetic Act for OTC drug products.

Chairman Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA) committed to working together to secure Senate passage of the bills. The Chairman did not provide a timeline for action. He indicated he hopes to advance additional measures “later this Congress” on palliative care and the geriatric and pediatric workforces. – Christina Lavoie J.D.

Nursing Workforce Reauthorization Act Advances in House and Senate

On Oct. 28, the House of Representatives approved H.R.728, the Title VIII Nursing Workforce Reauthorization Act. Title VIII programs address specific nursing workforce needs by providing targeted funding to institutions that educate nurses, from entry-level to graduate study, for practice in rural and medically underserved communities. H.R. 728 would reauthorize federal funding for Title VIII programs to help grow and support the nursing workforce in the United States. On Oct. 31, the Senate Health, Education, Labor, and Pensions Committee also marked up the legislation, along with several other bipartisan health bills. - Lauren N. Lattany, M.P.S.

Open Enrollment Begins on Federal Health Insurance Exchange

The Federal Health Insurance Exchange (also known as the Marketplace) Open Enrollment Period runs from Nov. 1 to Dec. 15, 2019, for coverage starting on Jan. 1, 2020. As in previous years, the Centers for Medicare & Medicaid Services hopes to deliver a smooth enrollment experience and use consumer feedback to make improvements across the Exchange platform. New this year, consumers can visit HealthCare.gov to view quality rating information, in states that use HealthCare.gov, to help in their decision-making when comparing health coverage choices. – By Christina Lavoie J.D.

Number of Uninsured Children on the Rise

According to a new study from the Georgetown University Center for Children and Families, the number of uninsured children in the U.S. increased by more than 400,000 between 2016 and 2018, bringing the total to over 4 million uninsured children. The losses in coverage are widespread, with 15 states having statistically significant increases in the number and/or rate of uninsured children (Alabama, Arizona, Florida, Georgia, Idaho, Illinois, Indiana, Missouri, Montana, North Carolina, Ohio, Tennessee, Texas, Utah, and West Virginia). Loss of coverage is most prominent for white and Latino children, and children under age six, and in low- and moderate-income families who earn between 138% and 250% of the federal poverty level. States that have not expanded Medicaid to parents and other adults under the Affordable Care Act have seen increases in their rate of uninsured children three times as large as states that have.

On Oct. 29, House Energy and Commerce Committee Chairman Frank Pallone, Jr. (D-NJ) and Senate Finance Committee Ranking Member Ron Wyden (D-OR) sent a letter to Health and Human Services (HHS) Secretary Alex Azar, calling on HHS and the Centers for Medicare & Medicaid Services to “take immediate action to ensure that all eligible children are enrolled in Medicaid and CHIP.” The letter requests information on how and why the administration “presided over an unprecedented rise in the number of uninsured children in the United States, and what it plans to do to reverse this trend.”

Chairman Pallone and Ranking Member Wyden wrote that they believe “historic coverage losses among children are the result of overly burdensome and faulty eligibility and renewal processes, diminished resources for outreach and enrollment assistance, and policies that instill fear and confusion among immigrant and mixed status families,” adding that this is a “disturbing trend that the administration should be looking to correct.” The Chairman and Ranking Member requested a response by Nov. 30 regarding specific actions the administration will take to increase Medicaid and CHIP enrollment, as well as submission of related documents and analyses.  – Christina Lavoie J.D.

HHS Issues Final Rule that Rescinds Two Administrative Simplification Standards

The Department of Health and Human Services (HHS) recently released a final rule, titled “Administrative Simplification: Rescinding the Adoption of the Standard Unique Health Plan Identifier and Other Entity Identifier.” The rule will rescind the standard health plan identifier and the other entity identifier, which was recommended by the National Committee on Vital and Health Statistics. In December 2018, HHS opposed these actions because the cost and burden of implementing the identifiers outweighed any value they would provide due to the current the ability to route claims and other Health Insurance Portability and Accountability Act transactions using existing payer identifiers. The final rule also removes the definitions for the “controlling health plan” and “subhealth plan”. – Emma Achola

Senate Holds hearing on SUD; CMS and White House Release SUD Guidance

On Oct. 24, the Senate Finance Committee held a hearing entitled, “Treating Substance Misuse in America: Scams Shortfalls and Solutions.” The hearing focused on the quality of substance use disorder (SUD) treatment and recovery services. Ranking Member Ron Wyden (D-OR) indicated at the end of the hearing that a bipartisan coalition in the Senate is in the process of developing a plan to address concerns about SUD treatment.

Additionally, last week, the White House announced the launch of a new website that would be a resource for people suffering from SUD. The site will allow people to easily find addiction treatment, specifically focusing on those looking for opioid addiction treatment. The website, findtreatment.gov, enables users to search for particular treatments, as well as search for providers who take users’ insurance.

The Centers for Medicare & Medicaid Services also released an additional SUD resource: the first annual SUD Data Book. The release was a result of a mandate from the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act. Lawmakers, stipulating that the Administration “address the pressing need for SUD treatment and prevention services, with a focus on opioid use.” The book outlines several high level findings using data points from 2017. – Sarah Skirmont

FDA Issues Report on Drug Shortages

On Oct. 30, the U.S. Food and Drug Administration (FDA) issued a report, “Drug Shortages: Root Causes and Potential Solutions.” The report was conducted by the Drug Shortage Task Force, created in response to a congressional request in 2018. The FDA task force identified three main causes to the drug shortages, relying upon analysis of reports from stakeholders, published research, and economic analysis of market conditions.

1. Lack of incentives for manufacturers to produce less profitable drugs
2. Lack of market recognition and rewards for manufacturers
3. Logistical and regulatory challenges for the market to recover from disruption

The FDA also recommended three solutions to these causes:

1. Creating a shared understanding of the impact of drug shortages
2. Developing a rating system to incentivize drug manufacturers
3. Promoting private sector contracts to ensure reliable supplies of medically important drugs

Furthermore, the House Energy and Commerce Subcommittee on Health held a hearing on “Safeguarding the Pharmaceutical Supply Chain in a Global Economy.” The hearing addressed the development of generic and name brand pharmaceuticals, as well as the active pharmaceutical ingredients (API) present in both. The committee was concerned with the future development of APIs overseas. – Sarah Skirmont

AMGA in the News

Last week, AMGA was mentioned in the following news stories:

• October 31, 2019: Third Time’s a Charm? New Legislation Introduced to Remove Medicare Telehealth Restrictions; Healthcare Innovation
• October 29, 2019: Easing the Process of MSSP Quality Reporting; Managed Healthcare Executive