This Week – April 15, 2017

This Week in Washington, D.C.

  • 2017 ACG Governor Washington D.C. Fly-in
  • ACG Members: Get your coding questions answered
  • CMS Releases Affordable Care Act Market Stabilization Final Rule
  • MACRA Tidbit for the Week: MACRA and the Physician-Focused Payment Model Technical Advisory Committee

From ACG Board of Governors Chair, Costas Kefalas, MD, MMM, FACG

2017 ACG Governor Washington D.C. Fly-in

Dear ACG Colleagues:

I want to recognize the commitment of the many ACG Governors and ACG officers who took time away from their families and practices last week to advocate on behalf of ACG members and patients in Washington, D.C.

I am pleased to report that ACG had roughly 50 Governors and other College officers who attended the fly-in, which involved more than 300 meetings with members of the United States House of Representatives and United States Senate. The Governors carried a strong, clear message to legislators, representing the interests of practicing gastroenterologists. In taking ACG’s legislative priorities to Capitol Hill, the ACG Governors had the following key messages for Congress:

  • The Governors asked Members of Congress to co-sponsor the “Removing Barriers to Colorectal Cancer Screening Act of 2017” (S. 479; H.R. 1017). This bill corrects a quirk in the law and removes cost-sharing for a screening colonoscopy if polyps are removed.
  • Reduce burdens on private practice physicians under MIPS. The Governors educated congressional leaders and health policy staff about the administrative and regulatory burdens faced by practicing gastroenterologists. ACG Governors urged Congress to simplify MACRA by delaying the Resource Use category of MIPS until CMS can accurately attribute costs of providing services to patients. By emphasizing quality of care, and keeping the Quality component of MIPS the most significant weight of total MIPS scores, ACG believes that GI physicians may have more direct control over their quality reporting, thus having greater influence over defining their MIPS scores and, ultimately, Medicare reimbursement.
  • Adequately fund the National Institutes of Health (NIH)

Thank you ACG Governors!

The Board of Governors gathered in front of the Capitol building for the 2017 Annual Legislative Fly-In, Thursday, April 6th, 2017


ACG Members: Get your coding questions answered

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ACG, AGA, and ASGE Release 2017 CPT Coding Manual Update: ACG and the GI societies work closely together to ensure that our members are aware of, and prepared for, coding and reimbursement changes occurring each year.  For 2017, there were several changes to Current Procedural Terminology® (CPT) codes for gastroenterology services, including important changes for moderate sedation in Medicare.  The 2017 update also features 10 popular Q&As on coding.  ACG thanks Christopher Kim, MD, FACG and Daniel DeMarco, MD, FACG for their commitment to the College and representing ACG on these important CPT-related issues. Please review the 2017 CPT Coding Manual Update developed jointly by the three GI societies for your reference.


From ACG National Affairs Committee Chair, Whitfield L. Knapple, MD, FACG

CMS Releases Affordable Care Act Market Stabilization Final Rule

On April 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a final rule entitled Patient Protection and Affordable Care Act; Market Stabilization.  The final rule implements changes to “help stabilize the individual and small group markets and affirm the traditional role of State regulators.”

CMS is shortening the open enrollment period for 2018 in the individual markets to November 1 through December 15, 2017.  This is a change from the previously established November 1st through January 31st timeframe.  CMS is also revising their interpretation of the “Federal guaranteed availability” requirement (continuous coverage requirement) to allow issuers, subject to state law, to require all individuals to pay back past due premiums before enrolling into a plan with the same issuer the following year.   CMS is also increasing pre-enrollment verification of all applicable individual market special enrollment and making several additional changes to special enrollment periods that they believe could improve the risk pool, improve market stability, promote continuous coverage, and increase options for patients.

CMS estimated that health insurance premiums will be approximately 1.5% lower under the final rule. CMS also estimates that the final changes in actuarial value will lead to a 0.75% reduction in total premiums.  However, CMS notes that the net effect of these provisions on enrollment, premiums, and total premium tax credit payments are uncertain: premiums will tend to fall if more young and healthy individuals obtain coverage, adverse selection is reduced, and issuers are able to lower costs due to “reduced regulatory burden,” and offer greater flexibility in plan design. However, if changes result in lower enrollment, especially for younger, healthier adults, it will tend to increase premiums.

ACG is reviewing the final regulation and its impact to your patients and practices.

MACRA and the Physician-Focused Payment Model
Technical Advisory Committee

MACRA creates incentives for physicians to participate in Alternative Payment Models (APMs), including the development of “physician-focused payment models” or PFPMs. MACRA also creates the Physician-Focused Payment Model Technical Advisory Committee (PTAC) to make comments and recommendations to HHS on proposals submitted by individuals and stakeholder entities. HHS is required by MACRA to establish criteria for PFPMs and to respond to the recommendations of PTAC (but does not have to accept the recommendations). The final MACRA regulation outlined 10 criteria to guide the PTAC.

The PTAC recently completed a 2 day public meeting on April 10 and 11th to deliberate and vote on proposals for physician-focused payment models, including:

  1. Project Sonar: PTAC recommend for limited-scale testing. Project SONAR is currently being used in the private commercial market and aims to support patients with inflammatory bowel disease (IBD). SONAR uses software to “ping” patients to hopefully intervene early.
  2. The American College of Surgeon-Brandeis Advanced APM: PTAC recommended for limited scale testing. The proposal is designed to pay physicians based upon “episodes” of care via Medicare claims, potentially including GI procedures such as colonoscopy an EGD, and chronic care conditions in GI.

The next step is for PTAC to draft its report to the Secretary of HHS with recommendations and rationale for those recommendations. CMS will consider these recommendations, but is not obligated to accept them. PTAC’s next public meeting is June 5, 2017.

ACG supports innovative payment models if ACG members believe these models benefit their patients and fit into their practices. In comments to the PTAC, ACG urged the panel to remember the key criteria of flexibility and choice. The Project SONAR submission also emphasized voluntary participation. ACG members practice in a variety of settings, from large academic institutions to independent solo practices. Each setting poses unique practice-management and fiscal challenges.  ACG members should participate in payment models that are most suitable for their respective practices and patients. Some recently implemented Medicare initiatives, however, have required participation for certain physicians depending on the specialty or area of the country in which they practice. For example, there are mandatory Medicare bundled payments underway in cardiology and orthopedic surgery. CMS has delayed the start time for two of these models — a signal that HHS Secretary Tom Price, MD may not agree with mandatory participation. ACG remains opposed to mandatory participation, as this is not likely to further the goals of increasing flexibility and reducing reporting burdens as recently stated in MACRA.