This Week – July 1, 2017

This Week in Washington, D.C.

  • ACA Repeal Watch: Senate Scuttles Vote after CBO Report Released
  • At the State and Local Level: ACG Fighting Ancillary Services Reimbursement Medicaid Cuts in Ohio
  • CMS Releases “Sunshine Rule” Payment Data for 2016
  • MACRA Tidbit for the Week: CMS Estimates on MIPS Eligibility- Who has to participate in MACRA in 2017 vs. 2018?

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

ACA Repeal Watch: Senate Scuttles Vote after CBO Report Released

On Tuesday, June 27th, Senate Republicans decided to delay the planned vote on their health reform bill, the Better Care Reconciliation Act of 2017, which was released last week.  This bill is designed to repeal the Patient Protection and Affordable Care Act (ACA), and is the Senate’s response to the House-passed bill, the American Health Care Act of 2017.  The announcement to delay the vote came on the heels of the Congressional Budget Office’s (CBO) cost and coverage estimate released on Monday, June 26.  The major headline from the CBO score:

“The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.”

This led more Republicans to raise concerns and criticisms of the bill, leading Majority Leader Mitch McConnell (R-KY) to begin the process of courting support and offering to change the bill.  Earlier this year, Republican leaders scored a procedural win in allowing an ACA-repeal bill to move forward by a simple majority (as opposed to 60 votes needed to move to a final vote).  However, even getting to 50 votes has proven to be very difficult.  ACG welcomes this scenario, as the College continues to have grave concerns over the proposed policy changes to patient cost-sharing, essential health benefits, and protection for pre-existing conditions.  ACG is using this opportunity to work with like-minded organizations in getting this bill significantly improved.

Sen. McConnell’s plan heading into the July 4th congressional recess is to revise this draft in order to secure enough votes to pass the bill.  The tug-of-war is the same scenario that Speaker Paul Ryan (R-WI) experienced earlier this year, where conservatives wanted more ACA provisions repealed in order to get the costs of premiums down, but moderates supported provisions in the ACA related to insurance subsidies and Medicaid expansion.  This is one of the problems ACG has voiced concerns over and is currently speaking with policymakers about: the goal has become a test of political strategy and gamesmanship in order to get something passed, as opposed to an opportunity for getting the substantive issues correct.

What are some items that will likely be used to entice support?  What is ACG doing to get this bill improved?  What else should you know? Read the full blog here.

At the State and Local Level: ACG Fighting Ancillary Services
Reimbursement Medicaid Cuts in Ohio


ACG members in Ohio: we need your help!

ACG is working with the Ohio Gastroenterology Society and the Ohio State Medical Association in fighting forthcoming Medicaid reimbursement cuts to ancillary services, including pathology.  A last minute provision was recently added into the Ohio state biennial budget that cuts non-institutional radiology and pathology services by 5% from January 2018- July 2019.   ACG is urging Governor John Kasich to veto this provision in the budget, using his line-item veto authority.  This is counter to Medicaid payment policy because it incentivizes these services to be performed in more expensive healthcare settings (institutional facilities) and disproportionately impacts independent physician practices and facilities.

Get involved! Send a message to Governor Kasich here.

Remember to contact your ACG Governor on important state and local issues impacting you and your practice.

The ACG Board of Governors is one of the most unique aspects of the American College of Gastroenterology. Governors are ACG Fellows that are elected from the membership of a particular state or region. There are currently 76 Governors across seven different regions in the U.S. and abroad. The Board of Governors acts as a two-way conduit between College leadership and the membership at-large. This helps the College make certain it is meeting the evolving needs of the membership.  Contact your ACG Governor today.

CMS Releases “Sunshine Rule” Payment Data for 2016


On June 30th, CMS published the Program Year 2016 Open Payments data, along with newly submitted and updated payment records for Program Years 2013, 2014, and 2015.  ACG members can review the data here.  The Open Payments program requires that transfers of value by drug, device, biological, and medical supply manufacturers to physicians and teaching hospitals be published on a public website.  In Program Year 2016, applicable manufacturers and GPOs reported $8.18 billion in payments and ownership and investment interests to physicians and teaching hospitals. This amount is comprised of 11.96 million total records attributable to 630,824 physicians and 1,146 teaching hospitals.

Inaccurate data about you? Register here in order to review data reported about your practice.

CMS Estimates on MIPS Eligibility-
Who has to participate in MACRA in 2017 vs. 2018?

On June 20th, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2018 Medicare Quality Payment Program (QPP) proposed regulation. This regulation outlines the proposed requirements for the Merit-based Incentive Payment System (MIPS), as well as for qualified or “advanced” alternative payment models (APMs) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

In 2017, if you bill more than $30,000 to Medicare, and provide care to more than 100 Medicare patients per year, and you are a: physician; physician assistant; nurse practitioner; clinical nurse specialist; or a CRNA.  For 2018, however, CMS proposes to change this “low volume exclusion.”  The proposed exclusion would include clinicians with ≤ $90,000 in Part B allowed charges or ≤ 200 Part B beneficiaries.

This is important for a few reasons:

First, it is encouraging to see CMS easing clinicians in small practices into MACRA.  ACG has advocated for an orderly transition.  In 2017, CMS estimated that the “$30,000 or 100 Medicare patients” low-volume threshold would exclude roughly 383,500 clinicians.  The 2018 estimates are almost doubled.  In 2018, CMS estimates that roughly 647,200 clinicians would be excluded from MACRA.

Second, CMS notes that, after all the exclusions, only 36-37% of the 1.5 million clinicians billing Medicare Part B services would actually be subject to MIPS.  However, please note that CMS seems to include all Medicare Part B clinicians in this calculation instead of the subset of types of clinicians who have to participate in MACRA (see provider type above), which is roughly 1.3 million according to the proposed rule.  Therefore, this would increase the percentage to roughly 42-44%.  But still, less than 50% of Medicare Part B clinicians are estimated to participate in MIPS next year, which equals to approximately 555,000 to 572,300 clinicians (depending on data model).  This is comparable to CMS’ estimate of 53-57% of clinicians excluded from MIPS in 2017.  Thus, it is encouraging to see CMS continuing to ease providers into MACRA.

Of note: One major reason for these 2018 estimates is that roughly 572,300 Medicare Part B clinicians would be participating in an alternative payment model (APM).  Is this a lofty estimate? CMS estimated that in 2017, a range of 70,000-120,000 clinicians would qualify for an APM, and thus be excluded from MIPS.

GI estimates: CMS estimates that there are roughly 10,910 clinicians in 2018 that would be subject to MIPS (compared to 12,773 in 2017).

Stay tuned for more analysis in the CY 2018 MACRA proposed rule.