This Week – July 29, 2017

This Week in Washington, D.C.

  • ACA Repeal Watch: Early momentum leads to dramatic flop for Senate Republicans and Administration
  • Back by Popular Demand: Joint ACG-FDA Fellowship Program
  • MACRA Tidbit for the Week: A review of what it may take to get a MIPS bonus

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

ACA Repeal Watch: Early momentum leads to dramatic flop for Senate Republicans and Administration

In the early morning hours of Friday, July 28th, the Senate rejected a paired down, or “skinny repeal” version of the Patient Protection and Affordable Care Act (ACA).  Three Republicans: Sens. Susan Collins (R-ME), Lisa Murkowski (R-AK), and John McCain (R-AZ) joined 40 Senate Democrats to defeat this latest version of ACA repeal.  According to reports, Senate Republicans actually thought they had the 50 votes needed to pass this “skinny repeal bill.”  Vice President Pence and President Trump personally talked to Sen. McCain immediately prior to voting as well.

Click here to watch the shock on many Senators faces as Sen. McCain votes to oppose the bill.

It is important to note that while the late-night dramatics focused on Sen. McCain, many policy wonks in Washington D.C. were watching Sen. Murkowski’s vote, as reports surfaced that the Administration may be applying a lot of pressure on Sen. Murkowski to go along with the Republican bill(s).

The week actually started off strong for Senate Majority Leader Mitch McConnell (R-KY) and Republican leaders.  On Tuesday, they secured the requisite 50 votes (Vice President Pence was the tie breaker) necessary to get the bill to the Senate floor for a vote.  This required Sen. McCain to travel back to Washington D.C. after surgery and a diagnosis of brain cancer.

Things then got more interesting, as no one really knew what the “Bill” would ultimately be when it came time to vote.  The Bill started with Sen. McConnell’s latest version of the “Better Care Reconciliation Act of 2017.”  When that was voted down on Tuesday night, the Bill then became the ACA repeal bill that passed both the House and Senate in 2015 (President Obama vetoed).  That was voted down on Wednesday as well, forcing Sen. McConnell and the Trump Administration to huddle with Senate Republicans to come up with some sort of deal as the Senate voted on various political messaging amendments.  By Thursday evening, Sen. McConnell and leadership were doing the legislative equivalent of exasperated parents trying anything to get their toddlers to eat dinner before bedtime, urging their colleagues to get something/anything passed before the weekend.  By late Thursday evening, the Bill became the “Health Care Freedom Act,” or skinny repeal bill.  Elements included:

  • Repealing the ACA’s “individual mandate” to purchase health insurance, by zeroing out the penalty (beginning after December 31, 2015).
  • Repealing the ACA’s “employer mandate” by zeroing out the penalties for not providing employees any health insurance (only from January 1, 2016 to December 31, 2024).
  • Extending the moratorium on the medical device tax (December 31, 2017 to December 31, 2020).
  • Increasing for three years (2018 to 2020) the maximum contribution limit to health care savings accounts (HSA) to the amount of the deductible and out-of-pocket limitations.
  • Defunding Planned Parenthood for one year (also expanding the one-year defunding to certain other providers that provide abortions if they receive more than $1 million in federal and state funding).
  • Eliminating funding for the Prevention and Public Health Fund after FY 2018.
  • Providing $422 million in additional funding for the Community Health Center Program in 2017.
  • Amending “section 1332 of the ACA,” or the part of the ACA that Republican leadership in both the House and Senate were using to allow states to forgo essential health benefits, or other patient protections (Waiver for State Innovation).This new language gave $2 billion for states to submit or implement enhanced state innovation waivers, if the application meets certain benefit, cost-sharing, enrollment, and budgetary requirements.

The Health Care Freedom Act was ultimately voted down 49-51 at roughly 1:40 AM on Friday.

What’s next for health care reform? What is ACG doing? Read the full blog here.

Back by Popular Demand: Joint ACG-FDA Fellowship Program

Current fellows are invited to submit their application for a one-month rotation at the FDA, sponsored by ACG. The candidate chosen will have the opportunity to participate in daily FDA activities, and will gain first-hand knowledge of the drug and device approval process. The College will provide a stipend for travel and daily living expenses. All applications must be submitted directly to ACG, and will be reviewed by the ACG FDA Related Matters Committee along with staff at the FDA.

Upon completion of the rotation (while you are a fellow), the candidate will be invited by ACG to present his or her experiences at the following ACG Annual Scientific Meeting. The application process is now open. All applications must be submitted by September 22, 2017. The candidate will be chosen and notified of acceptance by November 2017.

For complete details regarding the FDA-ACG Fellowship Program, click here.

A review of what it may take to get a MIPS bonus

The very first ACG MACRA Tidbit for the Week discussed the “other guy must fail first” reimbursement structure of MIPS.   MACRA requires “budget neutrality,” or in other words, one provider must be cut for another to get a bonus.  There is also a non-budget neutral “exceptional performance” pool of funds for higher MIPS scores.  The “exceptional bonus” is a pool of $500 million (2019 – 2025).

As ACG has discussed in the past, CMS views both 2017 and (as of now) 2018 as “transition” years.  ACG applauds CMS for this transition.  It allows ACG members to avoid a payment cut by reporting a minimum amount of data until providers get their feet wet.  In a time of lower reimbursement for GI services, ACG’s policy goals have focused on reducing the regulatory burdens and “hassle factor” of participating in Medicare quality reporting programs that are tied to reimbursement.

The flip side to this transition phase, however, is that there could be little bonus money available for those participating in MIPS, even for higher scoring providers.  Recent CMS estimates demonstrate this dilemma:

CMS estimates that there are roughly 10,910 GI clinicians in 2018 that would be subject to MIPS (compared to 12,773 in 2017).  Of this number, 96.5% are estimated to avoid a reimbursement cut or be eligible for a bonus, while 3.5% of eligible GI clinicians would be subject to a payment cut in CY 2020.  What’s more, over 79% of eligible GI clinicians would qualify for the “exceptional bonus,” according to CMS estimates.  These estimates are comparable to MIPS-eligible clinicians in all specialties: where 96% of all eligible MIPS clinicians (total: 554,846) will at least avoid a cut, and of this group, 77% will be eligible for the exceptional bonus.

So that means if 3-4% of all eligible clinicians are subject to a cut, clearly there is very little bonus money to distribute to other providers.  Thus, unless you have a really high score, you can expect to simply avoid a cut in 2019 and 2020.  If 77-79% of the 554,846 eligible MIPS clinicians (427,231) are eligible for the “exceptional bonus,” then that would mean each provider would receive roughly $1,170 per clinician.  The less people who qualify for the “exceptional bonus,” the more this amount rises.  These figures are also similar to CMS’ estimates for the CY 2019 MIPS payment year.  For the 2019 payment year, CMS sets this “exceptional performance category” score at 70 (out of 100).  So know what you need to do this year in order to get to a score of 70.  ACG can help.

Participation in an approved registry like GIQuIC can help as well.  Since GIQuIC submits the data to CMS for you, it also helps reduce the practice management submission burdens and administrative hassle factors associated with MIPS requirements.  Click here to learn more.