Jun 21, 2016

MACRA Rule: Not What Congress Ordered


By Don Read, MDPresident, Texas Medical Association

(This article first appeared in the KevinMD.com blog. Reprinted with permission.)

I joined physicians nationwide last year in cheering when Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Not only did it eliminate the congressional budgetary fiction known as the Sustainable Growth Rate (SGR) formula, it also promised to simplify and improve Medicare’s costly and complex programs that purport to measure the quality of care we provide to our patients.

Unfortunately, as we review the draft implementing rule, it appears that the net result will be neither simplified nor improved. Frankly, while we see the need for some legislative tweaks, this proposed rule is not what Congress ordered.

MACRA already has accomplished two of its intended goals. It reauthorized the Children’s Health Insurance Program for two years, and it removed the constant threat of SGR-driven Medicare payment cuts. The SGR’s faulty assumptions would have forced annual fee cuts for physicians for every one of the past 15 years. The obvious folly of that policy drove Congress to override each of those cuts since 2002, often in desperate, last-minute or retroactive circumstances. The associated financial threats and uncertainty about business viability created continuously hazardous conditions for physicians.

MACRA also promised to simplify the ever-tightening thicket of federal regulations that strangle physicians’ practices. The draft regulations that the Centers for Medicare & Medicaid Services (CMS) published on May 9 fall far short of that promise. If implemented as written, they would dump additional bureaucratic work on physicians and their practices, and would continue to impose onerous federal controls on physicians and their practices — with no data to show that they would improve the quality of or access-to-care for patients. The system devised by CMS is far more costly, complex, and confusing than the costly, complex, and confusing programs it is replacing. Compliance would be especially difficult for small practices who may end up with Medicare payment penalties even if they spend the time and money to jump through all the new regulatory hoops. The budget-neutral system of bonuses and penalties pits physician practices against each other, so that there will be annually anointed winners and losers regardless of how well all practices “perform” on these new quality standards.

When MACRA legislation was enacted, TMA had no reason to expect CMS would propose to continue flawed concepts from the current quality programs along with plans to diminish a physician’s worth down to a complex point system. More disappointing is to learn that CMS proposes to design a program that is stacked against solo physicians and small group practices in its first year of implementation.

CMS and proponents of the agency’s proposed plan say it will streamline the current quality reporting systems and simplify the transition to value-based care. CMS Acting Administrator Andy Slavitt says “we have to get the hearts and minds of physicians back,” and he claims MACRA will “put physicians back in control.” Our analysis of the proposed regulations reveals something much to the contrary.

We found:
  • Costly Reporting and Compliance:
    The compliance, documentation, and reporting requirements related to the new combined incentive programs are inordinately costly for many physicians. CMS’ own figures show the new programs will add additional compliance costs of $128 million above the cost of the programs it is replacing.
  • Disjointed Timelines and Perverse Incentives:
    CMS has failed to properly engage physicians and guide them to successful participation since the current program began in 2007. The replacement does little to reverse the problems in the current systems, and in fact immediately increases the requirements for “success.” The first year of implementation is not the time to raise the bar and increase the degree of difficulty in meeting quality reporting requirements.
  • Metrics Outside of Physician Control:
    Vendors and patients, not physicians, have control over meeting MACRA’s standards and requirements. Physicians should not be penalized for the failures of their electronic health record (EHR) vendors or for the demographic or socioeconomic status of their patients.
  • Two Years Too Late:
    CMS plans to use two- year-old data to determine whether physicians receive a bonus or penalty. Data from 2017 will be used in 2019, 2018 data in 2020, and so on. At no point in the process will physicians be provided feedback on their current performance data or insights within the current performance year on how to improve their status, and no objective standard will exist for physicians to target. Physicians should be given real-time and correct information on their practices.
  • Arbitrary Incentives to Create Massive Changes in Physician Practice Type:
    The need for sophisticated support systems, the inflexibility of the measurement standards, and the lack of realistic incentives to change all create pressures for physicians to abandon small practices to join large ones — or to sell out to hospitals. In fact, CMS’ published data shows that payment penalties could decimate small practices, still the majority in Texas.
  • Cost Without Benefit to Medicare:
    There is no evidence that the incentives in the draft MACRA regulations are likely to be effective in improving care quality or increasing efficiency. Requirements should include only activities proven to actually enhance care quality, or to reduce cost with no adverse impact on quality, access, or productivity.
The nearly 50,000 physician and medical student members of the Texas Medical Association urge the leadership of CMS to chart a different course of action. We call on them to take the time necessary to ensure that this new law supports and enhances the physicians who provide the medical care to our nation’s 54 million Medicare beneficiaries. We urgently request that CMS stop moving down a path that threatens to plow under tens of thousands of physician practices and needlessly create an access crisis for patients covered by Medicare.

In general we are asking for time, fairness, simplicity, and flexibility. More precisely:
  • Exempt physicians who have no possibility of earning more than it costs them to report data, and do not force physicians into unacceptably risky payment models.
  • Establish objective and timely measurement and reporting systems that are simpler and less costly than those currently required. The focus should be improving care for all Medicare patients, not creating yearly physician winners and losers with payment affected two years after care has been delivered.

  • Use quality metrics that capture those activities that are under the physician’s control and have been shown to improve quality of care, enhance access-to-care, and/or reduce the cost of care. The focus should be on metrics that are most meaningful to a practice and its patients, not on what will result in the best “score.”
  • Allow physicians who want to shift to value-based care enough time to make this transition in a way that actually benefits their patients and does not cause undue collateral damage to their practices.
  • Require EHR vendors to build and maintain products that meet federal specifications rather than forcing physicians to purchase and constantly upgrade expensive and often-balky systems.
Last week I sat in the American Medical Association audience when Acting Administrator Slavitt said, “I am convinced that adding new regulations to an already busy health care system without improving how the pieces fit together just will not work.” He also said he wants to hear what practicing physicians think about this draft rule.

This practicing physician is telling Mr. Slavitt his plan just will not work. Change it.

Jun 12, 2016

VA Official Defends Proposed Scope of Practice Change

(CHICAGO) - The Department of Veterans Affairs’ plan to allow advance practice nurses (APRNs) to practice independently within the VA is “all about access,” a top official in the VA health care system told Texas physicians today.

"When we say independent practice for nurse practitioners, that's in the context of team-based care," a senior VA health official told the Texas Delegation to the American Medical Association. "I don't even know what an independent practitioner in the VA system would mean."

The official said VA “bet the farm around 2010 on the patient-centered medical home model” and depends on APRNs to help meet veterans’ growing demand for care within the VA system.

The Texas physicians, which included a number of military veterans, peppered the official with tough questions.

"Veterans deserve the highest and best care,” said Beaumont anesthesiologist Ray Callas, MD, a decorated U.S. Navy veteran of Operation Desert Storm. “In the most complicated cases, anesthesiologists should be in the lead."

Last month, the VA published a proposed rule that would allow APRNs — nurse anesthetists, nurse practitioners, nurse midwives, and clinical nurse specialists — to practice independently within the VA health system. While this doesn't change state scope-of-practice laws for APRNs working outside the VA system, it overrides those laws for care being provided inside the VA.

Veterans' service organizations and more than 90 members of Congress are opposing this change on the grounds it jeopardizes veterans' safety. Comments on the draft rule are due July 25. TMA, the American Medical Association, the Coalition of State Medical Societies, and other medical societies will file formal comments in strong opposition.

The draft rule has stirred a storm of protest, particularly from anesthesiologists. The official said the VA already has received about 20,000 comments on the proposal, more than it has ever received on a proposed rule.

TMA urges Texas doctors to take a few minutes to tell VA officials what they think of the plan. Submit comments on the government's rulemaking website or through the American Society of Anesthesiologists' Safe VA Care website.

Despite the official's talk of team-based care, Fort Worth pediatrician Gary Floyd, MD, said an important phrase is missing in the VA’s draft rule. “It needs to be ‘physician-led,’” he said. “Please put that language back in.”

If the VA adopts the rule as written, Dr. Floyd said, groups like TMA will find it more difficult to protect physician-led team-based care in state legislatures.

“It needs to be a physician-led team, whether it's CRNAs or primary care,” he said. “That is the hallmark of quality care.”

Mar 2, 2016

Wednesday Morning Memo: Election Day Turns Out Great for Doctors, Patients – and #TEXPAC

By Steve Levine
TMA VP – Communications

While much of the state was engrossed in the obviously engrossing Super Tuesday presidential primary results last night, the Texas Medical Association and TEXPAC teams were studying the legislative and congressional races that will have a big impact on medicine going forward. 

Bottom line: we liked what we saw in the party primaries for the Texas House and Senate and U.S. Congress. The candidates who support patients and physicians, by and large, did well – some surprisingly well.

We have a few important runoffs coming up on May 24, and the November general elections will be important at the top of the ballot and for some local races. But most of the makeup of the 2017 Texas Legislature and the 2017 Texas delegation in Congress was decided yesterday.

As TEXPAC Board Chair Brad Holland, MD, pointed out last month, “With so few competitive districts around the state, the action is now, in the party primaries. The men and women who win their party’s nominations in the next few weeks very likely will be the people who will be making the final decisions in the legislature and in the courtrooms next year.”

See all of TEXPAC's endorsed candidates in the March 1 races and a description of how TEXPAC decides who to endorse.

Here’s our wrap-up of key TEXPAC victories:

Texas House of Representatives:

  • Speaker Joe Straus won easily against an onslaught of money and words from outside his San Antonio district.
  • State Affairs Committee Chair Byron Cook of Corsicana, Insurance Committee Chair John Frullo of Lubbock, and Insurance Committee Vice Chair Sergio Muñoz of Palmview all defeated strong challengers.
  • Former State Rep. High Shine of Temple ousted Rep. Molly White of Belton, who had medicine's second-worst voting record in the 2015 legislative session.
  • Key allies of doctors and patients – Reps. J.D. Sheffield, DO, of Gatesville; Jason Villalba of Dallas; Sarah Davis of West University Place; and Cindy Burkett of Sunnyvale – all came home winners.
  • There will be another doctor in the House: Anesthesiologist Tom Oliverson, MD, of Houston won his primary and is unopposed in the fall.
  • TEXPAC-endorsed candidates won in three other open House seats. In a fifth open seat to replace retiring Public Health Committee Chair Myra Crownover of Denton, the TEXPAC-supported candidate is leading going into the May 24 runoff.

Texas Senate

  • In Senate District 24, we couldn't ask for anything better. Both of TEXPAC’s endorsed candidates -- one an active TMA leader (ophthalmologist Dawn Buckingham, MD, of Lakeway) and one a nurse married to a TMA past president (Rep. Susan King of Abilene) – are headed to the May 24 runoff.
  • The TEXPAC-endorsed candidate in Senate District 1 in East Texas is leading big going into the other Senate open seat runoff.

U.S. House of Representatives

  • Ways and Means Committee Chair Kevin Brady of The Woodlands defeated three opponents to win. His committee has primary jurisdiction over Medicare.
  • Medicine’s champion – Rep. Michael Burgess, MD, of Denton, the only TMA member in Congress, architect of the bill that repealed Medicare’s hated Sustainable Growth Rate (SGR) formula -- won handily.
  • Rep. Gene Green of Houston – ranking member of the Subcommittee on Health – won his race.

Nov 10, 2015

How to spur Congress to act: 7 essential elements of storytelling

Republished with permission from AMA Wire®


The struggle with electronic health records (EHR) is real, and Congress needs to hear from physicians.  But how can you make your story compelling? How can you pen a tale that cuts to the heart of the matter and inspires your members of Congress to take action? These seven elements of storytelling—recommended by an expert on engaging members of Congress—will help you craft the most potent version of your story.

In an AMA Very Influential Physicians (VIP) webinar last week, Brad Fitch, president and CEO of the Congressional Management Foundation, delivered expert advice on how physicians can compose and position their personal EHR stories in an effort to persuade Congress to take action against meaningful use Stage 3 and further progression of the program’s troublesome regulations.
Why is storytelling important for this cause?
Storytelling is a key part of the psychology of persuasion. We feel, and then we decide. In order for Congress to understand the detrimental effect meaningful use regulations have on daily practice, physicians need to deliver a perspective that will show the impact on their lives and the lives of their patients.
Members of Congress deal with a lot of data, spreadsheets and graphs every day, Fitch said. This type of information is being delivered to them all the time. But only physicians can communicate the personal stories from the front lines and drive them to act.
The 7 elements of storytelling
Your story should be brief. One page, single-spaced, is about 500 words. This length will take approximately four to six minutes to read aloud. If a story is too long, your members of Congress could lose interest, particularly with the numerous other demands for their attention, Fitch said, answering a listener’s question
Mark Twain once said, “I would have written a shorter letter, but I didn’t have the time.” Condensing your story can be difficult, but take the time to make it concise. A shorter story is more memorable and can leave a lasting impression, Fitch said.
When crafting your story, Fitch recommends using these seven elements of storytelling to most effectively communicate your experience with EHRs and regulations:
1.   “The Want”: Begin with the end in mind.
Know what you want before you begin. Do you want your member of Congress to understand how EHRs have increased costs to your practice or impacted the delivery of care to patients? A good storyteller begins knowing what the end product should deliver emotionally.

Consider various tactics and methods to achieve your goal in the story. Your goal can be to flatter, surprise, or evoke empathy or urgency. You are the Steven Spielberg of your story. What effect do you want to have on your audience?
2.   “The Opening”: Set the stage and establish the stakes.
Your first sentence or two should make your reader want to know more. What is at stake for patients, their families or you as the physician providing their care? As much as possible, think about the effect these regulations have on your ability to deliver quality care to your patients.

Members of Congress are listening for the component that tells them, “If I don’t do X, then Y will happen.”
3.   “Paint the Picture”: The details and senses of your story.
When you experienced the moment you are writing about, what did you see, hear, touch, taste and smell? These are the elements that will get your members of Congress involved in the story.

Remember to use adjectives to enhance the power of your narrative. Make it real. Be practical, specific and graphic—don’t hold anything back! What descriptive words could make your story compelling and interesting? For example, substitute “morose” for “sad” or use the word “devastated” rather than “upset.” These are the kinds of impact words that paint the picture of your story.
4.   “The Struggle”: Describe the fight.
Identify the conflict. Real struggles in life are mental, philosophical, emotional, physical—even internal. Every story has a protagonist and an antagonist, and the interactions between these two is where the conflict lies.

Don’t hesitate to play the underdog. Members of Congress love to come to the aid of the underdog. They want to help David win the battle against Goliath. Play that strength.
5.   “The Discovery”: Always surprise the legislator.
What did you learn or realize in the moment of your story? Find this answer and deliver it when it will have the most impact. Then describe how that learning impacted your life, the lives of your patients, the future of your practice and your ability to deliver quality care.

You may not have a discovery, but is there a part of your story that might surprise the legislator? If you can add a twist—a moment that truly delivers the scope of your struggle—then use it.
6.   “We Can Win!”: Introduce the potential of success and joy.
Success in a story is when the hero or heroine wins the fight or struggle. Joy is when the audience can participate and take part in the celebration of victory. If you can hook your members of Congress into feeling the impact of success and the joy that will follow, they become a part of your cause.

Think: “Senator/Representative, we have the opportunity to ….” Then describe how that victory will enhance your practice and the lives of patients and their families.
7.   “The Button”: Finish with a hook.
As you end your story, come up with a last line your members of Congress will always remember. Be thoughtful when composing your final line. Write it out and make it perfect. Have your ending sentence memorized when you’re speaking in person. This way, your member of Congress will remember it for the rest of the day.

Fitch related a particularly salient example. While delivering his story to a Congressman regarding his inability to acquire necessary medication, a veteran described a moment when his granddaughter asked him, “Poppy, why do your hands shake?” He looked at the Congressman and said, “What should I tell her?” This kind of hook will tug at the heart strings of your members of Congress and stay with them.
Once your story is drafted, revised and final, deliver it to your member of Congress. Visit breaktheredtape.org to send your story directly to Congress by email.
Remember to take your time. A well-crafted story, no matter how small, can hold remarkable power.
How to more actively reach your members of Congress
Become a member of the AMA’s “Very Influential Physicians (VIP)” program by visiting the AMA Grassroots Advocacy Web page to take part in future activities. You also can log in to view the full 7 elements of storytelling webinar.
By AMA staff writer Troy Parks

Nov 9, 2015

Health Insurers’ Narrow Networks Putting Squeeze on Patients

Health insurance companies are sharply limiting the number of physicians and hospitals they include in their networks as a tool to limit how much they have to pay in covered benefits. Narrow networks are booming in plans sold both through employer-sponsored insurance and on the Affordable Care Act (ACA) marketplace exchanges.

These moves leave patients out in the cold, and squeezed for the costs of health care the plans aren’t covering. The popular news media and scientific literature have been filled with stories lately about narrow networks. Here’s a roundup.

ACA Plans Lack Specialists


As many as 14 percent of health plans on the ACA exchanges lack physicians in at least one key specialty. That’s what researchers from Harvard’s T. H. Chan School of Public Health reported in the Journal of the American Medical Association. (“Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act,” JAMA, Oct. 27, 2015.)

“We found this practice among multiple states and issuers,” the authors wrote. “This likely violates network adequacy requirements, raising concerns regarding patient access to specialty care. Such plans precipitate high out-of-pocket costs and may lead to adverse selection (i.e., sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies.”

Rheumatologists, endocrinologists, and psychiatrists were the specialists most often missing from the plans.

Texas Leads in “X-small” ACA Networks

Texas has more “x-small” networks (45 percent) on the ACA exchange than any other state in the network. That’s what the Leonard Davis Institute of Health Economics (LDI) at the University of Pennsylvania found. (“State Variation in Narrow Networks on the ACA Marketplaces,” published by the Robert Wood Johnson Foundation, August 2015.) Those super-shrunken networks offer access to 10 percent or fewer of the physicians in a rating area. 

This study looked at plans issued by 267 carriers across 355 networks in all 50 states. It used “t-shirt size” ratings of x-small (less than 10 percent), small (10 percent-25 percent), medium (25 percent-40 percent), large (40 percent-60 percent), and x-large (more than 60 percent). The variation was extensive. Some states, such as Delaware, Kansas, and North Dakota, have mostly large or x-large networks. Others don’t at all.

Here are the states with the most x-small or small networks:
  • Georgia – 83 percent
  • Florida – 79 percent
  • Oklahoma – 78 percent
  • California – 75 percent
  • Texas – 73 percent
  • Arizona – 73 percent
In an earlier study, the authors at the Davis Institute found that 41 percent of silver plans on the ACA exchanges were x-small or small. 

Half of ACA Hospital Networks Are Narrow

Patients’ choice of hospitals on the ACA exchange plans is similarly limited. That’s what the McKinsey Center for U.S. Health System Reform found. (“Hospital networks: Evolution of the configurations on the 2015 exchanges,” published by McKinsey & Co., April 2015.)

“Across the country, close to half of the 2015 networks that consumers can choose from are narrowed; in the largest cities, almost two-thirds of the networks are narrowed,” the report states.

The report defines a “narrow” network as having 70 percent or fewer of local hospitals participating. An “ultra-narrow” network has 30 percent or fewer participating.

“Many consumers, however, do not appear to understand the choices available to them or the impact of those choices (especially limits on access to care),” McKinsey found. “In our consumer survey, 44 percent of those who bought an ACA plan for the first time this year reported that they did not know the network configuration associated with their plan.”

Half of ACA Plans Don’t Cover Out of Network


Another study found that 47 percent of the plans sold on the federal ACA exchange have no coverage for out-of-network care. In Texas, that number is 67 percent. (“Almost Half of Obamacare Plans on Federal Marketplace Lack Out-Of-Network Coverage,” published by HealthPocket, Oct. 7, 2015.)

That, HealthPocket explains, means “the plans will not cover the costs except in the case of a medical emergency or if a prior authorization from the plan had been formally submitted and then approved by the health plan.”

Narrow Networks Forcing Patients to the ED

Because of narrow networks, a survey of emergency department doctors found, patients are showing up sicker in the emergency department. Also, emergency physicians are finding fewer primary care doctors and specialists to whom they can refer patients for follow-up. (“Insurance Industry Drives Patients to Sacrifice Necessary Medical Care,” published by American College of Emergency Physicians [ACEP], Oct. 26, 2015.)

Specifically, the national study of emergency physicians found:
  • 73 percent of the doctors see more Medicaid patients because insurance companies don’t provide enough primary care or specialty physicians for their patients.
  • 65 percent see more patients in the emergency department, in large part because health insurance companies don’t provide enough primary care physicians to support the community.
  • 60 percent have difficulty finding specialists for their patients, because of narrow networks.
  • More than 80 percent treat patients who said they had difficulty finding specialists to care for them because health plans have narrow networks.  
“This is a scary environment for patients,” said Jay Kaplan, MD, president of ACEP. “The insurance companies are shifting costs onto patients and medical providers as they attempt to increase their bottom lines, and this threatens the foundation of our nation’s medical care system.”

Health Plans Mount Lackluster PR Campaign

Trying to escape the cascade of negative publicity, the insurance industry issued a report blaming physicians’ overcharges for medical care as the cause of “surprise bills.” (“Texas doctors, insurers taking ‘balance billing’ fight public,” Houston Chronicle, Oct. 11, 2015; “Doctors fire back at insurance industry report on what Texans are charged for ER visits,” Quorum Report, Oct. 8, 2015)

It didn’t work. The news media saw right through it and reported this comment from TMA President Tom Garcia, MD:
This so-called report is nothing more than a desperate smoke screen to divert attention from the real problem. The health insurance industry games the system to keep more of patients’ premium dollars by forcing patients to seek care out of network. Then they have the gall to criticize what some doctors’ bill for that care.
And the San Antonio Express-News published a response to the study from William W. Hinchey, MD. 

“Insurers want your local pathologist in the network only for inpatient hospital services but not for your outpatient services — even when the pathologist wants to be in your network for both,” Dr. Hinchey explained. “The insurance company ultimately decides who will be in or out of your network. Essentially the insurers are saying to the physicians: We want you some of the time but not all the time.”


The Real Truth About Balance Billing

A TMA study examines how insurance plans’ network designs and payment decisions leave many Texans with “surprise bills” for health care services.

Inadequate and limited physician networks that insurers sell today are leaving patients with unpaid bills. Unfortunately, Texas consumers are learning the limits of the coverage they bought just when most need coverage, especially in emergencies. The consumer is no longer satisfied with the not-very-well-explained, varying levels of savings that insurance networks create, especially if that means a greater financial burden in emergencies. Yet, despite network shortcomings, consumers do not want to be left without the choice of plans that offer network benefits.



Nov 5, 2015

What Exactly IS Wrong With EHRs?

Many thanks to David Fleeger, MD, of Austin, a member of the TMA Board of Trustees, for taking the time to explain electronic health records and Meaningful Use on this TV show. He even managed to work in "Meaningless Use."

Sep 30, 2015

Get Social This Month With a Free Book Excerpt From TMA

Looking for a road map to arrive at a stronger social media presence? This month, we’re offering help to get you more social savvy.

During October, visit the TMA Education Center to download a free excerpt of Get Social: Put Your Practice on the Social Media Map by TMA’s Steve Levine and Debra Heater. Get Social explains how to use popular social media sites like Twitter, Facebook, YouTube, and others. The book offers handy tools and insights for physicians, medical students, and office staff interested in engaging with patients, and the public, on these platforms. You’ll also find advice and best practices for using social media responsibly and avoiding potential HIPAA pitfalls.

Download your free excerpt. The free excerpt will be available through Oct. 31.