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November 2016
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The Votes Are In
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The ballots have been cast and counted and your AMGA team is preparing to welcome a new Congress and administration in Washington. With the stunning election of Donald Trump, we expect a busy year for healthcare policy in Congress. President-elect Trump said repeatedly and emphatically on the campaign trail that he will repeal the Affordable Care Act (ACA).

House and Senate Republicans have been saying the very same thing for six years, so there is ample opportunity for the new White House and Congress to relitigate the ACA. Repealing the ACA would impact every corner of the healthcare system, including of course, AMGA members. Moreover, repeal legislation may come with attempts to reform Medicare and Medicaid, meaning there could be fewer covered lives and decreased federal healthcare funding after 2017.

Clearly, 2017 will be an important year, and we hope you'll work with us as we represent your interests in Washington, D.C. If you have any questions regarding the new administration and Congress, please contact me at any time. By the way, we held a webinar last week that provided an analysis of the election results and what it means for AMGA members. If you missed it, a recording and the presentation are available on our website.

One of the issues we expect Congress to consider next year is reforming the Medicare Shared Savings Program (MSSP). Because of that, I'm very pleased that our featured guest columnist for this issue of AMGA Advocate is Rep. Dianne Black (R-TN), who is co-sponsoring the ACO Improvement Act of 2016. AMGA supports this bill, which includes a number of reforms to the MSSP that are a priority for our members and would improve the long-term viability of the program.

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Featured Column: Bipartisan Solutions for Seniors' Health Challenges
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By Congressman Diane Black (R-TN-06)

Before I came to Congress, I was on the front lines of our healthcare system as an emergency room and long-term care nurse. Throughout my more than 40 years in the industry, I saw how healthcare decisions in Washington impacted real people, and I learned about the challenges we face in delivering care to those with chronic health conditions.

I also learned that, in order to provide Americans with the care they deserve, we should not have to ask more of American taxpayers. The Federal Government spends nearly $1 trillion on healthcare programs each year. So instead of simply throwing more money at the problem, we need to spend our dollars more effectively to improve the value of care delivered.

One way we can do that is by addressing manageable problems before they become big problems. Today, at least half of all Americans have one or more chronic health conditions and treating those conditions accounts for roughly 86 percent of our nation's healthcare costs.

We all know that regularly taking doctor-prescribed medication is an important step in preventing chronic health issues from escalating into more serious, life-altering conditions that place an added burden on patients, their families, and the healthcare system. But with such a simple solution, why aren't more people taking their medication?

As anyone with a chronic health condition will tell you, sticking to a constant regimen of medication isn't cheap. A person with diabetes, for example, could end up spending $250 a month on test trips and $200 a month or more on insulin.

Health savings accounts (HSAs), while a great alternative to traditional healthcare plans for many, can present a barrier to those with chronic health conditions because the consumer will continue paying a higher price for their maintenance medications and necessary services until their deductible - which can be thousands of dollars - is met.

One of the most promising approaches to addressing the cost of medication without overstepping the government's bounds in the marketplace is Value-Based Insurance Design (V-BID). Instead of the current, one-size-fits-all approach to cost-sharing or copayments, V-BID embraces the idea that, by lowering a patients' out-of-pocket costs for essential prescription drugs and services, consumers will then be motivated to stick to their regimen and stay healthier - in turn decreasing the overall long-term costs to our healthcare system.

Based on these facts, I introduced H.R. 5652, the Access to Better Care Act of 2016, alongside Congressman Earl Blumenauer (D-OR). Our legislation removes financial barriers by letting HSAs paired with high-deductible plans provide patients with the medicine and services necessary to manage their chronic health conditions on a pre-deductible basis. Federal regulations already allow this for certain types of preventive care, and it only makes sense to create a separate exception for medications and services people depend on to manage a chronic condition. By working to ease these costs for patients, we can help them stick to their medication regimens and live longer, healthier lives.

The Access to Better Care Act isn't a cure-all for our healthcare challenges. It is part of what must be a larger effort to reform the system – an effort I believe should also include improving the value, cost, and accessibility of care by improving coordinated care for our nation’s seniors. One commonsense way to do this is by removing barriers for accountable care organizations (ACOs).

ACOs can play an important role in ensuring better coordination of care for Medicare beneficiaries, but today, their successes are hindered by countless regulatory hurdles. Some of these barriers include restrictions on telehealth, remote patient monitoring, and primary care cost-sharing. Unlike the current system, we must offer regulatory relief for ACOs so they can provide patient-centered, cost-effective, quality care to Medicare beneficiaries.

That is why I also penned H.R. 6101, the bipartisan ACO Improvement Act of 2016 with Rep. Peter Welch (D-VT). This legislation seeks to tackle these barriers and give ACOs the tools needed to be successful in the ACO program. Some other specific provisions of the bill include a choice of prospective or retrospective assignment of beneficiaries, bonus payments for quality achievement and improvement - allowing ACOs to move up the risk track on an annual basis - and expanding the ability of non-physician providers to participate in rural and underserved areas.

With the release of the final Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule in October, it is more important than ever for ACOs to have the flexibility to take on more risk, move up the risk tracks, and participate in the Advanced Alternative Payment Models of the program. I am hopeful that legislation such as this will allow ACOs to free themselves of the regulatory burden and focus on providing integrative care for beneficiaries.

The Congressional calendar may offer little hope for passage of these bills before the end of the year, but our bipartisan coalition of support will continue working to advance these policies until Congress gavels out for the last time in December.

Right now, that means doing a lot of member education. Colleagues of mine without a healthcare background won't always know the complexities of this issue and the very real ways their constituents could benefit from these solutions, so that is what we hope to explain.

I am glad to be introducing these items of legislation with lead cosponsors like Congressman Blumenauer and Congressman Welch because our colleagues know that we may disagree on other issues, but if members like us can come together and champion the same bill, there is good reason for them to support it too.

Americans want to see Congress act on meaningful, bipartisan, real-world solutions, and I know that my colleagues in Washington want this as well. The Access to Better Care Act and the ACO Improvement Act offer an opportunity to do exactly that, while reducing barriers to quality, affordable health care for those who need it most.

Congressman Diane Black is a registered nurse representing Tennessee's 6th District. She serves on the Ways and Means Health Subcommittee and is a member of the GOP Doctors Caucus.

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Legislative Update

The election results from November 8 will have a dramatic effect on the legislative agenda in Congress for the foreseeable future. President-elect Donald Trump takes office in January and a new will be sworn in that is controlled by the Republican Party.

Many professional pollsters indicated before Election Day that former Secretary of State Hillary Clinton would prevail and the Senate would flip into control of the Democrats. Some professional pundits even claimed the House could return to control of the Democratic Party. What happened in this historic election proved the polling community wrong and will force that industry to reassess its methods. President-elect Trump won the Electoral College vote with key swing state victories in Ohio, Florida, and Pennsylvania. He even was able to win the state of Wisconsin, which had not voted Republican at the presidential level since the 1980s. Republicans in the Senate had their majority reduced from 54 to 51, with one race heading to a runoff in December. On the other side of the Hill, House Republicans saw a decrease in the majority by around 8 members, but they still have at least 238 members (with 4 races still to be called), well above the 218 required for a majority and control of the House. All in all, the Republican Party witnessed a major victory on Election Day.

One of the President-elect's first agenda items will be to staff his administration. This process will include appointments to department level and agency heads, such as the Secretary of Health and Human Services and Administrator of the Centers for Medicare & Medicaid Services. Many of these political appointees require Senate confirmation, so Republican control of the Senate is crucial.

With Republican majorities in both chambers of Congress, President-elect Trump's major campaign promise to repeal the Affordable Care Act (ACA) may be an attainable goal to a degree. Republicans have passed legislation in the past that eliminates much of the ACA's foundation, such as the employer/individual mandates and premium subsidies. However, repealing the ACA in total could have repercussions that lawmakers may have difficulty explaining to their constituents. Millions likely will lose health coverage, which could pose obvious political problems for the President-elect and members of Congress. How President-elect Trump handles this policy and political mine field will take up much of his first 100 days in office.

While the Senate will remain under Republican control, their majority will be slimmer with a caucus of at least 51 members. The state of Louisiana will have a runoff in December, which will determine the final majority. Sen. Mitch McConnell (R-KY) likely will remain Majority Leader and be willing to work with the new Republican White House. The current Senate Minority Leader Harry Reid (D-NV) is retiring, and Sen. Charles Schumer (D-NY) is expected to ascend into this leadership position. Sens. McConnell and Schumer are well known in Washington, D.C., as solutions-oriented dealmakers. That ability to work together will be key for the Senate to pass legislation. The Republicans only have a simple majority and for the most part, the Senate requires 60 votes to pass most legislation.

The House Republicans remain in control of their chamber, albeit with a fewer Republicans serving. Previously, they had 246 Republican seats, but in the new Congress, their numbers will have decreased to 238. Current Speaker Paul Ryan (R-WI) will likely retain his leadership post and attempt to be a policy confidant to the new Trump administration. Speaker Ryan is known for his domestic policy knowledge and could be a key player as the new administration attempts reform to programs such as the ACA.

In Congress, one of the President-elect's greatest assets could be Vice President-elect Mike Pence. Before becoming Governor of Indiana, Pence was a House Republican, and he was a respected conservative leader who was solutions-oriented. Pence's relationship with both chambers of Congress could be critical to the White House and Congress having a fruitful relationship.

AMGA will continue to advocate for you as the political landscape continues to evolve.

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Regulatory Update

The Centers for Medicare & Medicaid Services (CMS) recently finalized the agency's Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS). AMGA priorities were addressed in both final rules. In addition, AMGA expects CMS to finalize its proposed Part B drug pricing demonstration before the end of the year.

Regarding the Calendar Year (CY) 2017 Medicare Physician Fee Schedule, which pays for services provided by physicians and other eligible Part B practitioners, the rule finalizes revisions to payments for chronic care management, including new codes for payment for complex chronic care management. In our comments in response to the proposed PFS rule, we indicated our support for the proposed changes to improve the implementation of the 2014-initiated Chronic Care Management (CCM) code and stressed the importance of providers and patients discussing their plan of care and working together to make sure all the patient's providers and family caregivers are fully informed. CMS finalized the provision.

In the final rule, CMS also finalized payments related to specific behavioral health services furnished using the psychiatric Collaborative Care Model, under which patients are cared for via a team approach involving a primary care practitioner, behavioral health care manager, and a psychiatric consultant. The final rule incudes AMGA's recommendation that the agency institute a broad view of what patient encounters would qualify for payment under the model.

Under the 2017 OPPS final rule, CMS finalized a proposed change to the Electronic Health Record (EHR) program by finalizing a 90-day reporting period for 2016 and 2017. AMGA supported this proposal in our comment letter to CMS. The agency also finalized its proposal to eliminate the Clinical Decision Support (CDS) and Computerized Provider Order Entry (CPOE) objectives and measures for hospitals and Critical Access Hospitals (CAHs) that attest under the Medicare EHR Incentive program.

The OPPS rule also implements the site-neutral payment provisions, as required by Section 603 of the Bipartisan Budget Act of 2015. Certain items and services provided in off-campus, provider-based departments will not be considered covered outpatient services. Instead, these services will be paid under "the applicable payment system" - namely the Medicare Physician Fee Schedule - as of January 1, 2017. The rule does include exceptions. Those off-campus, provider-based departments that were billing under the OPPS before November 2, 2015 that have not relocated or changed ownership may continue to bill under the OPPS. Dedicated emergency departments and those provider-based departments within 250 yards of the hospital also are exempt.

Still pending is the Part B drug demonstration project. Currently, Medicare Part B pays physicians and hospital outpatient departments the average sales price (ASP) of a drug plus 6%. Under the proposed rule, the 6% add-on payment would be changed to 2.5% plus a flat fee payment of $16.80 per drug.

In other news, AMGA recently filed comments on a Request for Information on State Innovation Model (SIM) Concepts. CMS is interested in learning "ways to support broad payer and healthcare provider participation in alternative payment models." In our comments, we encouraged CMS to use future SIM funding to support state efforts to better align self-insured employer plans with Alternative Payment Model programming.

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MACRA Resources
Successful transformation from fee-for-service to value-based/risk payment arrangements requires a shift in physician compensation formulas. Check out our Compensation Techniques Used to Improve Provider Performance and Alignment Resource.
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Will the ACA Be repealed?
President-Elect Trump's victory provides him with some momentum to implement key campaign promises. In your opinion, will the Affordable Care Act be repealed? Vote here.
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The Results Are In
In our previous edition of the AMGA Advocate we asked our readers "In your opinion, who will become the 45th president of the United States of America?" The results were:

Hillary Clinton (D) - 62%
Donald Trump (R) - 38%
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