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Senate health care proposal already facing uphill battle
Senate Republican leaders are facing pushback from almost every side on their Affordable Care Act repeal/replace proposal – so much so that the current plan is unlikely to gain enough support to pass.
Sen. Rand Paul (R-Ky.), Sen. Ted Cruz (R-Texas), Sen. Ron Johnson (R-Wis.), and Sen. Mike Lee (R-Utah) said in a joint statement issued June 22, the day the plan was published, “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans to repeal Obamacare and lower their health care costs.”
Like the House-passed American Health Care Act (H.R. 1628), the proposed BCRA would reduce Medicaid spending and would address rising premiums in the individual health insurance marketplace; however, BCRA would take a slightly different path to the same destination.
Like the House bill, BCRA also targets funding for Planned Parenthood, although because of Senate procedural rules, it is a more indirect funding ban.
A key difference between BCRA and the House bill is how insurance premium support is calculated. The AHCA would base tax credits on age, providing a lesser benefit for older, but pre–Medicare-age adults. In contrast, BCRA would base tax credits on income while limiting eligibility to households at 350% of the federal poverty line. Further, credits would cover only 58% of the actuarial value of health insurance under BCRA.
The draft Senate plan would not allow states to request a waiver from the ACA’s so-called community waiver provisions – the portion of the law that requires health insurance premiums to be the same regardless of age or preexisting condition; the House-passed AHCA would allow those waivers.
Medicaid expansion would be rolled back under the Senate plan, but at a slower pace than the AHCA would require – by 2023 under BCRA vs. 2020 under AHCA.
The BCRA would establish a per capita funding mechanism for Medicaid going forward, which would base funding on historic Medicaid expenditures and uses an economic index to track inflation and adjust payments accordingly.
To address the needs of people with greater health care needs, the Senate proposal would provide $57 billion over the first 4 years, then another $57 billion over the next 8. The funds would be available for programs such as premium support or high-risk pools to help individuals who are expected to be high users of health care. States would be required to match funds starting in 2022.
Experts were quick to weigh in on the Senate plan.
The BCRA needs to do three things, according to Grace-Marie Turner, president of the Galen Institute: Provide a safety net for those covered through the ACA so that they do not lose coverage in the transition, modernize Medicaid, and give states more authority and options to reform their own health insurance markets.
“We have learned that the federal government is not able to regulate something as local as health insurance,” Ms. Turner said. “They cannot create policies and legislation that works for people in downtown Manhattan and rural Montana and southern New Mexico and the panhandle of Florida. There are too many different populations. The states need to do that, and this bill also would give the states more authority to begin to oversee their health insurance markets but with new funding to provide extra help for the people who have difficulty buying progress.”
She said it could be much better if the Senate did not use the reconciliation process, “but within the confines of that, both the House and Senate bills do the same thing.”
Ms. Turner also stressed that there are more reforms coming later, as the Senate and House address other portions of ACA repeal/replacement.
“I hope that [senators] would see moving this forward as beneficial so that then they can move additional pieces of legislation, hopefully, with 60 votes to go through the regular process, to have additional follow-up bills. This is not the end of the story. This is just rescuing us from Obamacare,” she said. “Then we need to go forward and think about what do we need to do to make our health sector work better in the future by putting doctors and patients, rather than government, in charge of choices.”
Doctors, however, did not agree.
“This bill significantly decreases patients’ ability to access high-quality health care, and affordable coverage for millions of Americans will be in jeopardy if the legislation is passed,” Boyd Buser, MD, a doctor of osteopathy and president of the American Osteopathic Association, said in a statement.
He noted that the Medicaid cuts will have a “devastating impact, especially in areas of our country hardest hit by the ongoing opioid epidemic. ... The Senate bill should have prioritized prevention and care coordination, two measures proven to reduce overall health costs by eliminating waste and addressing health problems at the most treatable stage. Decreasing the number of Americans with coverage as it intends does will not lower costs.”
In a statement from the American Gastroenterological Association, it was noted that steep cuts to Medicaid funding are a main driver of loss of coverage. Both bills also allow states to opt out of the Affordable Care Act’s essential health benefits package, which includes coverage of colorectal cancer screenings. “A core mission of AGA is to ensure that patients have access to high-quality medical care,” said Timothy Wang, MD, AGAF, AGA chair. “We have made great strides in the increase in screening and prevention of colorectal cancer, which reduces deaths and downstream health-care costs. Erecting barriers to screening will only reverse this progress.” The budget cuts and restrictions on patient access under the congressional proposals will create tremendous burdens for the health-care system as patients will increasingly rely on practices and academic medical centers to provide uncompensated care, according to the AGA.
Republican lawmakers and the Trump administration have vowed to address the ACA in other ways as well, by reviewing and possibly changing all relevant regulations, then using the regular legislative process, which would need 60 votes, to address issues that cannot be handled by the budget reconciliation process.
Senate Republican leaders are facing pushback from almost every side on their Affordable Care Act repeal/replace proposal – so much so that the current plan is unlikely to gain enough support to pass.
Sen. Rand Paul (R-Ky.), Sen. Ted Cruz (R-Texas), Sen. Ron Johnson (R-Wis.), and Sen. Mike Lee (R-Utah) said in a joint statement issued June 22, the day the plan was published, “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans to repeal Obamacare and lower their health care costs.”
Like the House-passed American Health Care Act (H.R. 1628), the proposed BCRA would reduce Medicaid spending and would address rising premiums in the individual health insurance marketplace; however, BCRA would take a slightly different path to the same destination.
Like the House bill, BCRA also targets funding for Planned Parenthood, although because of Senate procedural rules, it is a more indirect funding ban.
A key difference between BCRA and the House bill is how insurance premium support is calculated. The AHCA would base tax credits on age, providing a lesser benefit for older, but pre–Medicare-age adults. In contrast, BCRA would base tax credits on income while limiting eligibility to households at 350% of the federal poverty line. Further, credits would cover only 58% of the actuarial value of health insurance under BCRA.
The draft Senate plan would not allow states to request a waiver from the ACA’s so-called community waiver provisions – the portion of the law that requires health insurance premiums to be the same regardless of age or preexisting condition; the House-passed AHCA would allow those waivers.
Medicaid expansion would be rolled back under the Senate plan, but at a slower pace than the AHCA would require – by 2023 under BCRA vs. 2020 under AHCA.
The BCRA would establish a per capita funding mechanism for Medicaid going forward, which would base funding on historic Medicaid expenditures and uses an economic index to track inflation and adjust payments accordingly.
To address the needs of people with greater health care needs, the Senate proposal would provide $57 billion over the first 4 years, then another $57 billion over the next 8. The funds would be available for programs such as premium support or high-risk pools to help individuals who are expected to be high users of health care. States would be required to match funds starting in 2022.
Experts were quick to weigh in on the Senate plan.
The BCRA needs to do three things, according to Grace-Marie Turner, president of the Galen Institute: Provide a safety net for those covered through the ACA so that they do not lose coverage in the transition, modernize Medicaid, and give states more authority and options to reform their own health insurance markets.
“We have learned that the federal government is not able to regulate something as local as health insurance,” Ms. Turner said. “They cannot create policies and legislation that works for people in downtown Manhattan and rural Montana and southern New Mexico and the panhandle of Florida. There are too many different populations. The states need to do that, and this bill also would give the states more authority to begin to oversee their health insurance markets but with new funding to provide extra help for the people who have difficulty buying progress.”
She said it could be much better if the Senate did not use the reconciliation process, “but within the confines of that, both the House and Senate bills do the same thing.”
Ms. Turner also stressed that there are more reforms coming later, as the Senate and House address other portions of ACA repeal/replacement.
“I hope that [senators] would see moving this forward as beneficial so that then they can move additional pieces of legislation, hopefully, with 60 votes to go through the regular process, to have additional follow-up bills. This is not the end of the story. This is just rescuing us from Obamacare,” she said. “Then we need to go forward and think about what do we need to do to make our health sector work better in the future by putting doctors and patients, rather than government, in charge of choices.”
Doctors, however, did not agree.
“This bill significantly decreases patients’ ability to access high-quality health care, and affordable coverage for millions of Americans will be in jeopardy if the legislation is passed,” Boyd Buser, MD, a doctor of osteopathy and president of the American Osteopathic Association, said in a statement.
He noted that the Medicaid cuts will have a “devastating impact, especially in areas of our country hardest hit by the ongoing opioid epidemic. ... The Senate bill should have prioritized prevention and care coordination, two measures proven to reduce overall health costs by eliminating waste and addressing health problems at the most treatable stage. Decreasing the number of Americans with coverage as it intends does will not lower costs.”
In a statement from the American Gastroenterological Association, it was noted that steep cuts to Medicaid funding are a main driver of loss of coverage. Both bills also allow states to opt out of the Affordable Care Act’s essential health benefits package, which includes coverage of colorectal cancer screenings. “A core mission of AGA is to ensure that patients have access to high-quality medical care,” said Timothy Wang, MD, AGAF, AGA chair. “We have made great strides in the increase in screening and prevention of colorectal cancer, which reduces deaths and downstream health-care costs. Erecting barriers to screening will only reverse this progress.” The budget cuts and restrictions on patient access under the congressional proposals will create tremendous burdens for the health-care system as patients will increasingly rely on practices and academic medical centers to provide uncompensated care, according to the AGA.
Republican lawmakers and the Trump administration have vowed to address the ACA in other ways as well, by reviewing and possibly changing all relevant regulations, then using the regular legislative process, which would need 60 votes, to address issues that cannot be handled by the budget reconciliation process.
Senate Republican leaders are facing pushback from almost every side on their Affordable Care Act repeal/replace proposal – so much so that the current plan is unlikely to gain enough support to pass.
Sen. Rand Paul (R-Ky.), Sen. Ted Cruz (R-Texas), Sen. Ron Johnson (R-Wis.), and Sen. Mike Lee (R-Utah) said in a joint statement issued June 22, the day the plan was published, “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans to repeal Obamacare and lower their health care costs.”
Like the House-passed American Health Care Act (H.R. 1628), the proposed BCRA would reduce Medicaid spending and would address rising premiums in the individual health insurance marketplace; however, BCRA would take a slightly different path to the same destination.
Like the House bill, BCRA also targets funding for Planned Parenthood, although because of Senate procedural rules, it is a more indirect funding ban.
A key difference between BCRA and the House bill is how insurance premium support is calculated. The AHCA would base tax credits on age, providing a lesser benefit for older, but pre–Medicare-age adults. In contrast, BCRA would base tax credits on income while limiting eligibility to households at 350% of the federal poverty line. Further, credits would cover only 58% of the actuarial value of health insurance under BCRA.
The draft Senate plan would not allow states to request a waiver from the ACA’s so-called community waiver provisions – the portion of the law that requires health insurance premiums to be the same regardless of age or preexisting condition; the House-passed AHCA would allow those waivers.
Medicaid expansion would be rolled back under the Senate plan, but at a slower pace than the AHCA would require – by 2023 under BCRA vs. 2020 under AHCA.
The BCRA would establish a per capita funding mechanism for Medicaid going forward, which would base funding on historic Medicaid expenditures and uses an economic index to track inflation and adjust payments accordingly.
To address the needs of people with greater health care needs, the Senate proposal would provide $57 billion over the first 4 years, then another $57 billion over the next 8. The funds would be available for programs such as premium support or high-risk pools to help individuals who are expected to be high users of health care. States would be required to match funds starting in 2022.
Experts were quick to weigh in on the Senate plan.
The BCRA needs to do three things, according to Grace-Marie Turner, president of the Galen Institute: Provide a safety net for those covered through the ACA so that they do not lose coverage in the transition, modernize Medicaid, and give states more authority and options to reform their own health insurance markets.
“We have learned that the federal government is not able to regulate something as local as health insurance,” Ms. Turner said. “They cannot create policies and legislation that works for people in downtown Manhattan and rural Montana and southern New Mexico and the panhandle of Florida. There are too many different populations. The states need to do that, and this bill also would give the states more authority to begin to oversee their health insurance markets but with new funding to provide extra help for the people who have difficulty buying progress.”
She said it could be much better if the Senate did not use the reconciliation process, “but within the confines of that, both the House and Senate bills do the same thing.”
Ms. Turner also stressed that there are more reforms coming later, as the Senate and House address other portions of ACA repeal/replacement.
“I hope that [senators] would see moving this forward as beneficial so that then they can move additional pieces of legislation, hopefully, with 60 votes to go through the regular process, to have additional follow-up bills. This is not the end of the story. This is just rescuing us from Obamacare,” she said. “Then we need to go forward and think about what do we need to do to make our health sector work better in the future by putting doctors and patients, rather than government, in charge of choices.”
Doctors, however, did not agree.
“This bill significantly decreases patients’ ability to access high-quality health care, and affordable coverage for millions of Americans will be in jeopardy if the legislation is passed,” Boyd Buser, MD, a doctor of osteopathy and president of the American Osteopathic Association, said in a statement.
He noted that the Medicaid cuts will have a “devastating impact, especially in areas of our country hardest hit by the ongoing opioid epidemic. ... The Senate bill should have prioritized prevention and care coordination, two measures proven to reduce overall health costs by eliminating waste and addressing health problems at the most treatable stage. Decreasing the number of Americans with coverage as it intends does will not lower costs.”
In a statement from the American Gastroenterological Association, it was noted that steep cuts to Medicaid funding are a main driver of loss of coverage. Both bills also allow states to opt out of the Affordable Care Act’s essential health benefits package, which includes coverage of colorectal cancer screenings. “A core mission of AGA is to ensure that patients have access to high-quality medical care,” said Timothy Wang, MD, AGAF, AGA chair. “We have made great strides in the increase in screening and prevention of colorectal cancer, which reduces deaths and downstream health-care costs. Erecting barriers to screening will only reverse this progress.” The budget cuts and restrictions on patient access under the congressional proposals will create tremendous burdens for the health-care system as patients will increasingly rely on practices and academic medical centers to provide uncompensated care, according to the AGA.
Republican lawmakers and the Trump administration have vowed to address the ACA in other ways as well, by reviewing and possibly changing all relevant regulations, then using the regular legislative process, which would need 60 votes, to address issues that cannot be handled by the budget reconciliation process.
CBO: Senate health care proposal marginally better than House-passed bill
The Senate health care proposal is only marginally better in terms of the number of uninsured Americans, compared with the House-passed bill it aims to replace, but it still would leave 22 million more Americans without insurance coverage, according to a June 26 analysis by the Congressional Budget Office.
The analysis raised voices of opposition from the medical community.
BCRA would lower the federal deficit by $321 billion between 2017-2026, driven by the dramatic cuts in spending on Medicaid (estimated to be $772 billion), as well as $408 billion saved from reduced tax credits and other subsidies to help people afford health insurance.
The CBO’s estimate also addresses how the bill could impact access to health care.
Initially, patients can expect another short-term spike in insurance premiums, with average premiums in 2018 increasing by 20%, compared with current law, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” In 2019, premiums are predicted to be about 10% higher than under current law; however, by 2020, premiums for benchmark plans would be 30% lower than with current law.
However, as premiums come down, deductibles would continue to rise for plans that would offer lower levels of coverage, according to the CBO report. Additionally, “starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low income people. The deductible for a plan ... would be a significantly higher percentage of income – also making such a plan unattractive but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”
The report also notes that the Senate proposal would not necessarily reverse current concerns regarding consumer choice in the individual markets, stating that “a small fraction of the population resides in areas which – because of this legislation, for at least some of the years after 2019 – no insurers will participate in the nongroup market or insurance would be offered only with very high premiums.” Additionally, removing the employer mandate could result in employers forgoing offering health insurance to their employees.
The bill faces an uphill battle in the Senate as there seemingly are not enough votes to pass the bill at this time. The measure is using the budget reconciliation process, meaning it will need 50 of the 52 Senate Republicans to pass it (all 48 Democrats are expected to vote against it). At least six GOP senators have said they are not ready to start debate. Senate Majority Leader Mitch McConnell (R-Ky) will not present the bill to the chamber for consideration until after the July 4 recess in an effort to tweak the language to garner the 50 votes needed to pass.*
Medical societies are pushing back against the bill as well.
The American Medical Association, in a letter to Senate leaders, notes that the first principal that medical professionals operate under is to do no harm. “The draft legislation violates that standard on many levels,” according to the AMA letter.
The American Osteopathic Association reiterated its objections to BCRA in a statement, citing the CBO’s determination that 22 million would lose coverage.
“As patient advocates, we cannot accept that under [BCRA] patients in need will no longer have the coverage they require to access health care services,” the association said in a statement. “The BCRA does nothing to control health costs but instead focuses on reducing federal health care expenditures by cutting coverage of our nation’s most vulnerable individuals and eliminating policies that promote access to preventive care services that can actually drive down expenses while improving patient outcomes.”
The American College of Cardiology noted that CBO analysis “makes it clear that the [BCRA] would lead to loss of coverage for millions of Americans and limit access to care for our most vulnerable populations. ... The ACC opposes the BCRA as it does not align with our Principles for Health Reform, which stress the need for patient access to meaningful insurance coverage and high-quality care.”
*This article was updated on June 27, 2017.
The Senate health care proposal is only marginally better in terms of the number of uninsured Americans, compared with the House-passed bill it aims to replace, but it still would leave 22 million more Americans without insurance coverage, according to a June 26 analysis by the Congressional Budget Office.
The analysis raised voices of opposition from the medical community.
BCRA would lower the federal deficit by $321 billion between 2017-2026, driven by the dramatic cuts in spending on Medicaid (estimated to be $772 billion), as well as $408 billion saved from reduced tax credits and other subsidies to help people afford health insurance.
The CBO’s estimate also addresses how the bill could impact access to health care.
Initially, patients can expect another short-term spike in insurance premiums, with average premiums in 2018 increasing by 20%, compared with current law, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” In 2019, premiums are predicted to be about 10% higher than under current law; however, by 2020, premiums for benchmark plans would be 30% lower than with current law.
However, as premiums come down, deductibles would continue to rise for plans that would offer lower levels of coverage, according to the CBO report. Additionally, “starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low income people. The deductible for a plan ... would be a significantly higher percentage of income – also making such a plan unattractive but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”
The report also notes that the Senate proposal would not necessarily reverse current concerns regarding consumer choice in the individual markets, stating that “a small fraction of the population resides in areas which – because of this legislation, for at least some of the years after 2019 – no insurers will participate in the nongroup market or insurance would be offered only with very high premiums.” Additionally, removing the employer mandate could result in employers forgoing offering health insurance to their employees.
The bill faces an uphill battle in the Senate as there seemingly are not enough votes to pass the bill at this time. The measure is using the budget reconciliation process, meaning it will need 50 of the 52 Senate Republicans to pass it (all 48 Democrats are expected to vote against it). At least six GOP senators have said they are not ready to start debate. Senate Majority Leader Mitch McConnell (R-Ky) will not present the bill to the chamber for consideration until after the July 4 recess in an effort to tweak the language to garner the 50 votes needed to pass.*
Medical societies are pushing back against the bill as well.
The American Medical Association, in a letter to Senate leaders, notes that the first principal that medical professionals operate under is to do no harm. “The draft legislation violates that standard on many levels,” according to the AMA letter.
The American Osteopathic Association reiterated its objections to BCRA in a statement, citing the CBO’s determination that 22 million would lose coverage.
“As patient advocates, we cannot accept that under [BCRA] patients in need will no longer have the coverage they require to access health care services,” the association said in a statement. “The BCRA does nothing to control health costs but instead focuses on reducing federal health care expenditures by cutting coverage of our nation’s most vulnerable individuals and eliminating policies that promote access to preventive care services that can actually drive down expenses while improving patient outcomes.”
The American College of Cardiology noted that CBO analysis “makes it clear that the [BCRA] would lead to loss of coverage for millions of Americans and limit access to care for our most vulnerable populations. ... The ACC opposes the BCRA as it does not align with our Principles for Health Reform, which stress the need for patient access to meaningful insurance coverage and high-quality care.”
*This article was updated on June 27, 2017.
The Senate health care proposal is only marginally better in terms of the number of uninsured Americans, compared with the House-passed bill it aims to replace, but it still would leave 22 million more Americans without insurance coverage, according to a June 26 analysis by the Congressional Budget Office.
The analysis raised voices of opposition from the medical community.
BCRA would lower the federal deficit by $321 billion between 2017-2026, driven by the dramatic cuts in spending on Medicaid (estimated to be $772 billion), as well as $408 billion saved from reduced tax credits and other subsidies to help people afford health insurance.
The CBO’s estimate also addresses how the bill could impact access to health care.
Initially, patients can expect another short-term spike in insurance premiums, with average premiums in 2018 increasing by 20%, compared with current law, “mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.” In 2019, premiums are predicted to be about 10% higher than under current law; however, by 2020, premiums for benchmark plans would be 30% lower than with current law.
However, as premiums come down, deductibles would continue to rise for plans that would offer lower levels of coverage, according to the CBO report. Additionally, “starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low income people. The deductible for a plan ... would be a significantly higher percentage of income – also making such a plan unattractive but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan.”
The report also notes that the Senate proposal would not necessarily reverse current concerns regarding consumer choice in the individual markets, stating that “a small fraction of the population resides in areas which – because of this legislation, for at least some of the years after 2019 – no insurers will participate in the nongroup market or insurance would be offered only with very high premiums.” Additionally, removing the employer mandate could result in employers forgoing offering health insurance to their employees.
The bill faces an uphill battle in the Senate as there seemingly are not enough votes to pass the bill at this time. The measure is using the budget reconciliation process, meaning it will need 50 of the 52 Senate Republicans to pass it (all 48 Democrats are expected to vote against it). At least six GOP senators have said they are not ready to start debate. Senate Majority Leader Mitch McConnell (R-Ky) will not present the bill to the chamber for consideration until after the July 4 recess in an effort to tweak the language to garner the 50 votes needed to pass.*
Medical societies are pushing back against the bill as well.
The American Medical Association, in a letter to Senate leaders, notes that the first principal that medical professionals operate under is to do no harm. “The draft legislation violates that standard on many levels,” according to the AMA letter.
The American Osteopathic Association reiterated its objections to BCRA in a statement, citing the CBO’s determination that 22 million would lose coverage.
“As patient advocates, we cannot accept that under [BCRA] patients in need will no longer have the coverage they require to access health care services,” the association said in a statement. “The BCRA does nothing to control health costs but instead focuses on reducing federal health care expenditures by cutting coverage of our nation’s most vulnerable individuals and eliminating policies that promote access to preventive care services that can actually drive down expenses while improving patient outcomes.”
The American College of Cardiology noted that CBO analysis “makes it clear that the [BCRA] would lead to loss of coverage for millions of Americans and limit access to care for our most vulnerable populations. ... The ACC opposes the BCRA as it does not align with our Principles for Health Reform, which stress the need for patient access to meaningful insurance coverage and high-quality care.”
*This article was updated on June 27, 2017.
Senate health care proposal already facing uphill battle
Senate Republican leaders are facing pushback from almost every side on their Affordable Care Act repeal/replace proposal – so much so that the current plan is unlikely to gain enough support to pass.
“For a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor,” Sen. Rand Paul (R-Ky.), Sen. Ted Cruz (R-Texas), Sen. Ron Johnson (R-Wis.), and Sen. Mike Lee (R-Utah) said in a joint statement issued June 22, the day the plan was published. “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans to repeal Obamacare and lower their health care costs.”
Like the House-passed American Health Care Act (H.R. 1628), the proposed BCRA would reduce Medicaid spending and would address rising premiums in the individual health insurance marketplace; however, BCRA would take a slightly different path to the same destination.
Like the House bill, BCRA also targets funding for Planned Parenthood, although because of Senate procedural rules, it is a more indirect funding ban.
A key difference between BCRA and the House bill is how insurance premium support is calculated. The AHCA would base tax credits on age, providing a lesser benefit for older, but pre–Medicare-age adults. In contrast, BCRA would base tax credits on income while limiting eligibility to households at 350% of the federal poverty line. Further, credits would cover only 58% of the actuarial value of health insurance under BCRA.
The draft Senate plan would not allow states to request a waiver from the ACA’s so-called community waiver provisions – the portion of the law that requires health insurance premiums to be the same regardless of age or preexisting condition; the House-passed AHCA would allow those waivers.
Medicaid expansion would be rolled back under the Senate plan, but at a slower pace than the AHCA would require – by 2023 under BCRA vs. 2020 under AHCA.
The BCRA would establish a per capita funding mechanism for Medicaid going forward, which would base funding on historic Medicaid expenditures and uses an economic index to track inflation and adjust payments accordingly.
To address the needs of people with greater health care needs, the Senate proposal would provide $57 billion over the first 4 years, then another $57 billion over the next 8. The funds would be available for programs such as premium support or high-risk pools to help individuals who are expected to be high users of health care. States would be required to match funds starting in 2022.
Experts were quick to weigh in on the Senate plan.
The BCRA needs to do three things, according to Grace-Marie Turner, president of the Galen Institute: Provide a safety net for those covered through the ACA so that they do not lose coverage in the transition, modernize Medicaid, and give states more authority and options to reform their own health insurance markets.
“We have learned that the federal government is not able to regulate something as local as health insurance,” Ms. Turner said. “They cannot create policies and legislation that works for people in downtown Manhattan and rural Montana and southern New Mexico and the panhandle of Florida. There are too many different populations. The states need to do that, and this bill also would give the states more authority to begin to oversee their health insurance markets but with new funding to provide extra help for the people who have difficulty buying progress.”
She said it could be much better if the Senate did not use the reconciliation process, “but within the confines of that, both the House and Senate bills do the same thing.”
Ms. Turner also stressed that there are more reforms coming later, as the Senate and House address other portions of ACA repeal/replacement.
“I hope that [senators] would see moving this forward as beneficial so that then they can move additional pieces of legislation, hopefully, with 60 votes to go through the regular process, to have additional follow-up bills. This is not the end of the story. This is just rescuing us from Obamacare,” she said. “Then we need to go forward and think about what do we need to do to make our health sector work better in the future by putting doctors and patients, rather than government, in charge of choices.”
Doctors, however, did not agree.
“This bill significantly decreases patients’ ability to access high-quality health care, and affordable coverage for millions of Americans will be in jeopardy if the legislation is passed,” Boyd Buser, MD, a doctor of osteopathy and president of the American Osteopathic Association, said in a statement.
He noted that the Medicaid cuts will have a “devastating impact, especially in areas of our country hardest hit by the ongoing opioid epidemic. ... The Senate bill should have prioritized prevention and care coordination, two measures proven to reduce overall health costs by eliminating waste and addressing health problems at the most treatable stage. Decreasing the number of Americans with coverage as it intends does will not lower costs.”
A vote on the proposal could come as early as June 29 before the Senate breaks for the 4th of July recess.
Republican lawmakers and the Trump administration have vowed to address the ACA in other ways as well, by reviewing and possibly changing all relevant regulations, then using the regular legislative process, which would need 60 votes, to address issues that cannot be handled by the budget reconciliation process.
Senate Republican leaders are facing pushback from almost every side on their Affordable Care Act repeal/replace proposal – so much so that the current plan is unlikely to gain enough support to pass.
“For a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor,” Sen. Rand Paul (R-Ky.), Sen. Ted Cruz (R-Texas), Sen. Ron Johnson (R-Wis.), and Sen. Mike Lee (R-Utah) said in a joint statement issued June 22, the day the plan was published. “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans to repeal Obamacare and lower their health care costs.”
Like the House-passed American Health Care Act (H.R. 1628), the proposed BCRA would reduce Medicaid spending and would address rising premiums in the individual health insurance marketplace; however, BCRA would take a slightly different path to the same destination.
Like the House bill, BCRA also targets funding for Planned Parenthood, although because of Senate procedural rules, it is a more indirect funding ban.
A key difference between BCRA and the House bill is how insurance premium support is calculated. The AHCA would base tax credits on age, providing a lesser benefit for older, but pre–Medicare-age adults. In contrast, BCRA would base tax credits on income while limiting eligibility to households at 350% of the federal poverty line. Further, credits would cover only 58% of the actuarial value of health insurance under BCRA.
The draft Senate plan would not allow states to request a waiver from the ACA’s so-called community waiver provisions – the portion of the law that requires health insurance premiums to be the same regardless of age or preexisting condition; the House-passed AHCA would allow those waivers.
Medicaid expansion would be rolled back under the Senate plan, but at a slower pace than the AHCA would require – by 2023 under BCRA vs. 2020 under AHCA.
The BCRA would establish a per capita funding mechanism for Medicaid going forward, which would base funding on historic Medicaid expenditures and uses an economic index to track inflation and adjust payments accordingly.
To address the needs of people with greater health care needs, the Senate proposal would provide $57 billion over the first 4 years, then another $57 billion over the next 8. The funds would be available for programs such as premium support or high-risk pools to help individuals who are expected to be high users of health care. States would be required to match funds starting in 2022.
Experts were quick to weigh in on the Senate plan.
The BCRA needs to do three things, according to Grace-Marie Turner, president of the Galen Institute: Provide a safety net for those covered through the ACA so that they do not lose coverage in the transition, modernize Medicaid, and give states more authority and options to reform their own health insurance markets.
“We have learned that the federal government is not able to regulate something as local as health insurance,” Ms. Turner said. “They cannot create policies and legislation that works for people in downtown Manhattan and rural Montana and southern New Mexico and the panhandle of Florida. There are too many different populations. The states need to do that, and this bill also would give the states more authority to begin to oversee their health insurance markets but with new funding to provide extra help for the people who have difficulty buying progress.”
She said it could be much better if the Senate did not use the reconciliation process, “but within the confines of that, both the House and Senate bills do the same thing.”
Ms. Turner also stressed that there are more reforms coming later, as the Senate and House address other portions of ACA repeal/replacement.
“I hope that [senators] would see moving this forward as beneficial so that then they can move additional pieces of legislation, hopefully, with 60 votes to go through the regular process, to have additional follow-up bills. This is not the end of the story. This is just rescuing us from Obamacare,” she said. “Then we need to go forward and think about what do we need to do to make our health sector work better in the future by putting doctors and patients, rather than government, in charge of choices.”
Doctors, however, did not agree.
“This bill significantly decreases patients’ ability to access high-quality health care, and affordable coverage for millions of Americans will be in jeopardy if the legislation is passed,” Boyd Buser, MD, a doctor of osteopathy and president of the American Osteopathic Association, said in a statement.
He noted that the Medicaid cuts will have a “devastating impact, especially in areas of our country hardest hit by the ongoing opioid epidemic. ... The Senate bill should have prioritized prevention and care coordination, two measures proven to reduce overall health costs by eliminating waste and addressing health problems at the most treatable stage. Decreasing the number of Americans with coverage as it intends does will not lower costs.”
A vote on the proposal could come as early as June 29 before the Senate breaks for the 4th of July recess.
Republican lawmakers and the Trump administration have vowed to address the ACA in other ways as well, by reviewing and possibly changing all relevant regulations, then using the regular legislative process, which would need 60 votes, to address issues that cannot be handled by the budget reconciliation process.
Senate Republican leaders are facing pushback from almost every side on their Affordable Care Act repeal/replace proposal – so much so that the current plan is unlikely to gain enough support to pass.
“For a variety of reasons, we are not ready to vote for this bill, but we are open to negotiation and obtaining more information before it is brought to the floor,” Sen. Rand Paul (R-Ky.), Sen. Ted Cruz (R-Texas), Sen. Ron Johnson (R-Wis.), and Sen. Mike Lee (R-Utah) said in a joint statement issued June 22, the day the plan was published. “There are provisions in this draft that represent an improvement to our current health care system, but it does not appear this draft as written will accomplish the most important promise that we made to Americans to repeal Obamacare and lower their health care costs.”
Like the House-passed American Health Care Act (H.R. 1628), the proposed BCRA would reduce Medicaid spending and would address rising premiums in the individual health insurance marketplace; however, BCRA would take a slightly different path to the same destination.
Like the House bill, BCRA also targets funding for Planned Parenthood, although because of Senate procedural rules, it is a more indirect funding ban.
A key difference between BCRA and the House bill is how insurance premium support is calculated. The AHCA would base tax credits on age, providing a lesser benefit for older, but pre–Medicare-age adults. In contrast, BCRA would base tax credits on income while limiting eligibility to households at 350% of the federal poverty line. Further, credits would cover only 58% of the actuarial value of health insurance under BCRA.
The draft Senate plan would not allow states to request a waiver from the ACA’s so-called community waiver provisions – the portion of the law that requires health insurance premiums to be the same regardless of age or preexisting condition; the House-passed AHCA would allow those waivers.
Medicaid expansion would be rolled back under the Senate plan, but at a slower pace than the AHCA would require – by 2023 under BCRA vs. 2020 under AHCA.
The BCRA would establish a per capita funding mechanism for Medicaid going forward, which would base funding on historic Medicaid expenditures and uses an economic index to track inflation and adjust payments accordingly.
To address the needs of people with greater health care needs, the Senate proposal would provide $57 billion over the first 4 years, then another $57 billion over the next 8. The funds would be available for programs such as premium support or high-risk pools to help individuals who are expected to be high users of health care. States would be required to match funds starting in 2022.
Experts were quick to weigh in on the Senate plan.
The BCRA needs to do three things, according to Grace-Marie Turner, president of the Galen Institute: Provide a safety net for those covered through the ACA so that they do not lose coverage in the transition, modernize Medicaid, and give states more authority and options to reform their own health insurance markets.
“We have learned that the federal government is not able to regulate something as local as health insurance,” Ms. Turner said. “They cannot create policies and legislation that works for people in downtown Manhattan and rural Montana and southern New Mexico and the panhandle of Florida. There are too many different populations. The states need to do that, and this bill also would give the states more authority to begin to oversee their health insurance markets but with new funding to provide extra help for the people who have difficulty buying progress.”
She said it could be much better if the Senate did not use the reconciliation process, “but within the confines of that, both the House and Senate bills do the same thing.”
Ms. Turner also stressed that there are more reforms coming later, as the Senate and House address other portions of ACA repeal/replacement.
“I hope that [senators] would see moving this forward as beneficial so that then they can move additional pieces of legislation, hopefully, with 60 votes to go through the regular process, to have additional follow-up bills. This is not the end of the story. This is just rescuing us from Obamacare,” she said. “Then we need to go forward and think about what do we need to do to make our health sector work better in the future by putting doctors and patients, rather than government, in charge of choices.”
Doctors, however, did not agree.
“This bill significantly decreases patients’ ability to access high-quality health care, and affordable coverage for millions of Americans will be in jeopardy if the legislation is passed,” Boyd Buser, MD, a doctor of osteopathy and president of the American Osteopathic Association, said in a statement.
He noted that the Medicaid cuts will have a “devastating impact, especially in areas of our country hardest hit by the ongoing opioid epidemic. ... The Senate bill should have prioritized prevention and care coordination, two measures proven to reduce overall health costs by eliminating waste and addressing health problems at the most treatable stage. Decreasing the number of Americans with coverage as it intends does will not lower costs.”
A vote on the proposal could come as early as June 29 before the Senate breaks for the 4th of July recess.
Republican lawmakers and the Trump administration have vowed to address the ACA in other ways as well, by reviewing and possibly changing all relevant regulations, then using the regular legislative process, which would need 60 votes, to address issues that cannot be handled by the budget reconciliation process.
Physician-created APMs: Dermatology aims to learn from early recommendations
Dermatologists looking for a way to participate in an advanced alternative payment model under Medicare’s new Quality Payment Program will likely need to develop their own and get it approved.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher-value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they do not appeal to everyone.
“The likelihood that a private practice dermatologist is going to participate in a risk-bearing APM is, I think, possible but challenging,” said Kathryn Schwarzenberger, MD, chair of the American Academy of Dermatology’s Workgroup on Innovation in Payment and Delivery. “To have a fully qualified, double-sided risk APM for most private practitioners is going to be difficult. The advanced APMs, unless you are in a group, we have figured most dermatologists wouldn’t be interested.”
A physician-created APM might be a different story, however.
Getting approval for this type of APM – technically known as physician-focused payment models (PFPMs) – is tough. Of the first three PFPMs reviewed by Medicare’s Physician-Focused Payment Model Technical Advisory Committee (PTAC), two were recommended for limited trial periods only. A third proposal was not recommended. None of these early proposals were dermatology focused.
Not jumping into the process early was a prudent move, according to Dr. Schwarzenberger.
“We learned that it is probably good to sit back at this point and watch and see what is happening,” she said. “I think the rules have become much more clear. I think now that PTAC has provided us with some better guidelines for how to develop a successful APM, we have a much better chance of doing so.”
In this earliest review, each proposed APM was assigned to three commissioners, including at least one physician, for review against 10 criteria:
• Scope of proposed PFPM (high priority).
• Quality and cost (high priority).
• Payment methodology (high priority).
• Value over volume.
• Flexibility.
• Ability to be evaluated.
• Integration and care coordination.
• Patient choice.
• Patient safety.
• Health information technology.
While each proposal met a few of the criteria, none met all three high-priority criteria, and none was recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We recommended the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence are required before they may be ready.”
The two models that got the limited recommendation were:
• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a Web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
• American College of Surgeons–Brandeis APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacramento.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model: “Really understand the criteria and review the request for proposals. I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straightforward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee for service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Dr. Schwarzenberger said that while the AAD working group is looking at some dermatology-specific conditions that might be good for a PFPM a broader approach may be better. Perhaps the focus should be “where dermatology’s involvement with other physicians, where we might be able to help them practice medicine better or save money,” she said. “Maybe where we can make our biggest financial and potentially quality impacts.”
Dermatologists looking for a way to participate in an advanced alternative payment model under Medicare’s new Quality Payment Program will likely need to develop their own and get it approved.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher-value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they do not appeal to everyone.
“The likelihood that a private practice dermatologist is going to participate in a risk-bearing APM is, I think, possible but challenging,” said Kathryn Schwarzenberger, MD, chair of the American Academy of Dermatology’s Workgroup on Innovation in Payment and Delivery. “To have a fully qualified, double-sided risk APM for most private practitioners is going to be difficult. The advanced APMs, unless you are in a group, we have figured most dermatologists wouldn’t be interested.”
A physician-created APM might be a different story, however.
Getting approval for this type of APM – technically known as physician-focused payment models (PFPMs) – is tough. Of the first three PFPMs reviewed by Medicare’s Physician-Focused Payment Model Technical Advisory Committee (PTAC), two were recommended for limited trial periods only. A third proposal was not recommended. None of these early proposals were dermatology focused.
Not jumping into the process early was a prudent move, according to Dr. Schwarzenberger.
“We learned that it is probably good to sit back at this point and watch and see what is happening,” she said. “I think the rules have become much more clear. I think now that PTAC has provided us with some better guidelines for how to develop a successful APM, we have a much better chance of doing so.”
In this earliest review, each proposed APM was assigned to three commissioners, including at least one physician, for review against 10 criteria:
• Scope of proposed PFPM (high priority).
• Quality and cost (high priority).
• Payment methodology (high priority).
• Value over volume.
• Flexibility.
• Ability to be evaluated.
• Integration and care coordination.
• Patient choice.
• Patient safety.
• Health information technology.
While each proposal met a few of the criteria, none met all three high-priority criteria, and none was recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We recommended the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence are required before they may be ready.”
The two models that got the limited recommendation were:
• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a Web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
• American College of Surgeons–Brandeis APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacramento.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model: “Really understand the criteria and review the request for proposals. I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straightforward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee for service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Dr. Schwarzenberger said that while the AAD working group is looking at some dermatology-specific conditions that might be good for a PFPM a broader approach may be better. Perhaps the focus should be “where dermatology’s involvement with other physicians, where we might be able to help them practice medicine better or save money,” she said. “Maybe where we can make our biggest financial and potentially quality impacts.”
Dermatologists looking for a way to participate in an advanced alternative payment model under Medicare’s new Quality Payment Program will likely need to develop their own and get it approved.
Advanced alternative payment models (APMs) involve physicians taking on two-sided risk along with Medicare in exchange for the potential for higher bonus payments for delivering higher-value care to patients. Officials at the Centers for Medicare & Medicaid Services have created seven APMs (some primary care and some specialty focused), but they do not appeal to everyone.
“The likelihood that a private practice dermatologist is going to participate in a risk-bearing APM is, I think, possible but challenging,” said Kathryn Schwarzenberger, MD, chair of the American Academy of Dermatology’s Workgroup on Innovation in Payment and Delivery. “To have a fully qualified, double-sided risk APM for most private practitioners is going to be difficult. The advanced APMs, unless you are in a group, we have figured most dermatologists wouldn’t be interested.”
A physician-created APM might be a different story, however.
Getting approval for this type of APM – technically known as physician-focused payment models (PFPMs) – is tough. Of the first three PFPMs reviewed by Medicare’s Physician-Focused Payment Model Technical Advisory Committee (PTAC), two were recommended for limited trial periods only. A third proposal was not recommended. None of these early proposals were dermatology focused.
Not jumping into the process early was a prudent move, according to Dr. Schwarzenberger.
“We learned that it is probably good to sit back at this point and watch and see what is happening,” she said. “I think the rules have become much more clear. I think now that PTAC has provided us with some better guidelines for how to develop a successful APM, we have a much better chance of doing so.”
In this earliest review, each proposed APM was assigned to three commissioners, including at least one physician, for review against 10 criteria:
• Scope of proposed PFPM (high priority).
• Quality and cost (high priority).
• Payment methodology (high priority).
• Value over volume.
• Flexibility.
• Ability to be evaluated.
• Integration and care coordination.
• Patient choice.
• Patient safety.
• Health information technology.
While each proposal met a few of the criteria, none met all three high-priority criteria, and none was recommended for approval by its preliminary reviewers; however, after committee deliberation, two received provisional recommendation.
“We recommended the two models for small-scale testing,” PTAC Vice-Chairman Elizabeth Mitchell said in an interview. “Even though we think they are very good ideas, we know that more experience and evidence are required before they may be ready.”
The two models that got the limited recommendation were:
• Project Sonar, submitted by the Illinois Gastroenterology Group and SonarMD, a Web-based platform that queries patients with inflammatory bowel disease monthly to determine which are in need of more hands-on care.
• American College of Surgeons–Brandeis APM, submitted by the American College of Surgeons, an episode-based payment model that uses claims data but expands on existing CMS value-based models by not requiring hospitalizations. It creates an episodic payment using outpatient settings, including acute and chronic care.
The COPD [chronic obstructive pulmonary disease] and Asthma Monitoring Project (CAMP), a smartphone app to remotely monitor and guide treatment of patients with asthma and chronic obstructive pulmonary disease, was not recommended. It was submitted by Pulmonary Medicine, Infectious Disease and Critical Care Consultants Medical Group of Sacramento.
PTAC has received more than 20 letters of intent from physicians and aims to hold another round of public hearings in September to determine their usefulness.
“I think it is very safe to say that our whole committee has been really gratified with the level of interest and engagement,” said Ms. Mitchell, president and CEO of Network for Regional Healthcare Improvement in Portland, Maine. The volume of applications “underscores the level of interest from the field. The entire reason PTAC was established was to get those good ideas from practicing physicians and others who are identifying better ways to deliver care but are facing barriers in the current payment system.”
She offered advice to those who are contemplating submission of a payment model: “Really understand the criteria and review the request for proposals. I think the committee lays out what we are looking for in terms of information, and we are hoping that it is really straightforward.”
She also stressed that successful models need to work broadly. “We are not talking about something that works for a single practice,” she said. “We are talking about models that are ready for inclusion in the whole CMS portfolio. It is helpful if there is experience to draw from that informs our deliberations, but we recognize that, in some cases, there has not been the opportunity to test these models broadly.”
Most of all, the highest priority when it comes to the models is related to quality of care and cost.
“We are not soliciting models that are essentially tweaks to fee for service. We are looking for changes that cannot be made without a new method of payment,” she said, adding that the models “have to either reduce cost while maintaining quality or improve quality without raising cost.”
Meeting transcripts and video are posted online and can help potential applicants see how the committee came to its recommendations.
“The committee does not deliberate on the proposals except in public,” Ms. Mitchell said. “So, those public meetings were the first time we had deliberated on any of the proposals we have considered. The preliminary review teams have discussed it [in depth], but the full committee can only deliberate in public.”
Dr. Schwarzenberger said that while the AAD working group is looking at some dermatology-specific conditions that might be good for a PFPM a broader approach may be better. Perhaps the focus should be “where dermatology’s involvement with other physicians, where we might be able to help them practice medicine better or save money,” she said. “Maybe where we can make our biggest financial and potentially quality impacts.”
CMS proposes exempting more practices from MACRA
The Centers for Medicare & Medicaid Services seeks to exempt more practices participating in Medicare’s Quality Payment Program, the value-based payment program created by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Currently, physicians who receive $30,000 or less in Medicare Part B payments or have 100 or fewer Medicare patients are exempt from QPP but may choose to participate. The proposed rule for the second year of QPP (calendar year 2018) would raise the threshold to $90,000 or less in Part B payments or 200 or fewer Medicare patients. The proposed rule was released June 20.
Under QPP, physicians and practices that are not exempt will choose one of two tracks – the Merit-Based Incentive Payment System (MIPS), which will pay bonuses based on meeting certain quality thresholds, or the advanced alternative payment models (APMs), under which physicians will assume more risk in exchange for greater potential rewards for quality improvement.
“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” CMS Administrator Seema Verma said in a statement. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”
The proposed rule also introduces the framework for the development of “virtual groups,” a mechanism by which small and solo practices who meet the eligibility requirements for participating in MIPS can pool their reporting into the program to make it easier to share in the bonuses for meeting quality thresholds.
The Centers for Medicare & Medicaid Services seeks to exempt more practices participating in Medicare’s Quality Payment Program, the value-based payment program created by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Currently, physicians who receive $30,000 or less in Medicare Part B payments or have 100 or fewer Medicare patients are exempt from QPP but may choose to participate. The proposed rule for the second year of QPP (calendar year 2018) would raise the threshold to $90,000 or less in Part B payments or 200 or fewer Medicare patients. The proposed rule was released June 20.
Under QPP, physicians and practices that are not exempt will choose one of two tracks – the Merit-Based Incentive Payment System (MIPS), which will pay bonuses based on meeting certain quality thresholds, or the advanced alternative payment models (APMs), under which physicians will assume more risk in exchange for greater potential rewards for quality improvement.
“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” CMS Administrator Seema Verma said in a statement. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”
The proposed rule also introduces the framework for the development of “virtual groups,” a mechanism by which small and solo practices who meet the eligibility requirements for participating in MIPS can pool their reporting into the program to make it easier to share in the bonuses for meeting quality thresholds.
The Centers for Medicare & Medicaid Services seeks to exempt more practices participating in Medicare’s Quality Payment Program, the value-based payment program created by Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Currently, physicians who receive $30,000 or less in Medicare Part B payments or have 100 or fewer Medicare patients are exempt from QPP but may choose to participate. The proposed rule for the second year of QPP (calendar year 2018) would raise the threshold to $90,000 or less in Part B payments or 200 or fewer Medicare patients. The proposed rule was released June 20.
Under QPP, physicians and practices that are not exempt will choose one of two tracks – the Merit-Based Incentive Payment System (MIPS), which will pay bonuses based on meeting certain quality thresholds, or the advanced alternative payment models (APMs), under which physicians will assume more risk in exchange for greater potential rewards for quality improvement.
“We’ve heard the concerns that too many quality programs, technology requirements, and measures get between the doctor and the patient,” CMS Administrator Seema Verma said in a statement. “That’s why we’re taking a hard look at reducing burdens. By proposing this rule, we aim to improve Medicare by helping doctors and clinicians concentrate on caring for their patients rather than filling out paperwork.”
The proposed rule also introduces the framework for the development of “virtual groups,” a mechanism by which small and solo practices who meet the eligibility requirements for participating in MIPS can pool their reporting into the program to make it easier to share in the bonuses for meeting quality thresholds.
GOP senators shutting out physician input on reform – ASCO CEO
WASHINGTON – Physician associations are having an easy time finding people on Capitol Hill willing to listen when it comes to health care reform, but it appears that the conversations are falling on deaf ears, according to Clifford Hudis, MD, CEO of the American Society of Clinical Oncology.
“I am dismayed that our opinions are not being valued,” Dr. Hudis said at a policy summit hosted by the National Comprehensive Cancer Network.
He was critical of the current skyrocketing prices of oncology treatments but noted that, the way the current market is set up, there is no incentive anywhere in the system to put any pressure on manufacturers.
“Right now, the market forces, such as they are, not only allow this but encourage it and probably will continue to do so for a little longer,” he said, adding that the environment is such that “a majority of Americans want the government to do something about price. Think about that for a minute. That is a call for regulation, indirectly or directly. That’s a call for oversight. It’s a call for something different from the traditional open workings of a free market.”
He noted that, at least conceptually, the Trump administration is following in the footsteps of the Obama administration with an emphasis on value over volume, shared risk, and looking for improved outcomes.
In that vein, Dr. Hudis said there are rumblings that the much-criticized Part B demonstration that would put more emphasis on value-based payments to physicians for Part B drugs could return in some form, though he had no further details.
“Our position is that physicians should be accountable for utilization, for quality of care, and not for the price of the drug at market entry,” he said, noting ASCO’s opposition to the Part B demonstration as it was originally proposed.
That demonstration also highlighted another issue of value, particularly when there are no traditional market forces in play to help exert downward pressure on prices.
Defining value is problematic, and Dr. Hudis criticized the many value frameworks – including ASCO’s – as a signal that there is not enough being done to let the market truly make its determination on what is value.
“When we superimpose something like the value framework on this, we are essentially admitting a kind of defeat,” he said. “We are admitting that there won’t be traditional bid-counterbid price setting. There will instead be a declaration of value ultimately leading to pricing.”
“They are a declaration that somebody, through opinion or formula, will start to tell you collectively what a therapy is worth,” he added. “That’s like somebody telling you what an automobile is worth. It doesn’t really work that way in the rest of your world. You make a judgment for yourself about what something is worth. … One thing I know for sure is that for most patients, most new drugs are not worth their current price.”
WASHINGTON – Physician associations are having an easy time finding people on Capitol Hill willing to listen when it comes to health care reform, but it appears that the conversations are falling on deaf ears, according to Clifford Hudis, MD, CEO of the American Society of Clinical Oncology.
“I am dismayed that our opinions are not being valued,” Dr. Hudis said at a policy summit hosted by the National Comprehensive Cancer Network.
He was critical of the current skyrocketing prices of oncology treatments but noted that, the way the current market is set up, there is no incentive anywhere in the system to put any pressure on manufacturers.
“Right now, the market forces, such as they are, not only allow this but encourage it and probably will continue to do so for a little longer,” he said, adding that the environment is such that “a majority of Americans want the government to do something about price. Think about that for a minute. That is a call for regulation, indirectly or directly. That’s a call for oversight. It’s a call for something different from the traditional open workings of a free market.”
He noted that, at least conceptually, the Trump administration is following in the footsteps of the Obama administration with an emphasis on value over volume, shared risk, and looking for improved outcomes.
In that vein, Dr. Hudis said there are rumblings that the much-criticized Part B demonstration that would put more emphasis on value-based payments to physicians for Part B drugs could return in some form, though he had no further details.
“Our position is that physicians should be accountable for utilization, for quality of care, and not for the price of the drug at market entry,” he said, noting ASCO’s opposition to the Part B demonstration as it was originally proposed.
That demonstration also highlighted another issue of value, particularly when there are no traditional market forces in play to help exert downward pressure on prices.
Defining value is problematic, and Dr. Hudis criticized the many value frameworks – including ASCO’s – as a signal that there is not enough being done to let the market truly make its determination on what is value.
“When we superimpose something like the value framework on this, we are essentially admitting a kind of defeat,” he said. “We are admitting that there won’t be traditional bid-counterbid price setting. There will instead be a declaration of value ultimately leading to pricing.”
“They are a declaration that somebody, through opinion or formula, will start to tell you collectively what a therapy is worth,” he added. “That’s like somebody telling you what an automobile is worth. It doesn’t really work that way in the rest of your world. You make a judgment for yourself about what something is worth. … One thing I know for sure is that for most patients, most new drugs are not worth their current price.”
WASHINGTON – Physician associations are having an easy time finding people on Capitol Hill willing to listen when it comes to health care reform, but it appears that the conversations are falling on deaf ears, according to Clifford Hudis, MD, CEO of the American Society of Clinical Oncology.
“I am dismayed that our opinions are not being valued,” Dr. Hudis said at a policy summit hosted by the National Comprehensive Cancer Network.
He was critical of the current skyrocketing prices of oncology treatments but noted that, the way the current market is set up, there is no incentive anywhere in the system to put any pressure on manufacturers.
“Right now, the market forces, such as they are, not only allow this but encourage it and probably will continue to do so for a little longer,” he said, adding that the environment is such that “a majority of Americans want the government to do something about price. Think about that for a minute. That is a call for regulation, indirectly or directly. That’s a call for oversight. It’s a call for something different from the traditional open workings of a free market.”
He noted that, at least conceptually, the Trump administration is following in the footsteps of the Obama administration with an emphasis on value over volume, shared risk, and looking for improved outcomes.
In that vein, Dr. Hudis said there are rumblings that the much-criticized Part B demonstration that would put more emphasis on value-based payments to physicians for Part B drugs could return in some form, though he had no further details.
“Our position is that physicians should be accountable for utilization, for quality of care, and not for the price of the drug at market entry,” he said, noting ASCO’s opposition to the Part B demonstration as it was originally proposed.
That demonstration also highlighted another issue of value, particularly when there are no traditional market forces in play to help exert downward pressure on prices.
Defining value is problematic, and Dr. Hudis criticized the many value frameworks – including ASCO’s – as a signal that there is not enough being done to let the market truly make its determination on what is value.
“When we superimpose something like the value framework on this, we are essentially admitting a kind of defeat,” he said. “We are admitting that there won’t be traditional bid-counterbid price setting. There will instead be a declaration of value ultimately leading to pricing.”
“They are a declaration that somebody, through opinion or formula, will start to tell you collectively what a therapy is worth,” he added. “That’s like somebody telling you what an automobile is worth. It doesn’t really work that way in the rest of your world. You make a judgment for yourself about what something is worth. … One thing I know for sure is that for most patients, most new drugs are not worth their current price.”
AT NCCN POLICY SUMMIT
What’s driving the ‘failure’ of the ACA marketplaces?
Two reports from the Centers for Medicare & Medicaid Services show declines in the number of consumers who are activating the health insurance purchased via an Affordable Care Act exchange, a development Trump administration officials say underlines the failure of the ACA.
As of March 15, 10.3 million people paid premiums to activate coverage they purchased on the exchanges out of 12.2 million who enrolled in plans as of the Jan. 31 deadline for 2017, according to a June 12 report from CMS.
Further, some consumers who began paying premiums stopped.
Two key factors are behind the drop off, according to a second CMS report.
According to a voluntary online survey of consumers who left the exchanges between August 2016 and April 2017, 46% who canceled coverage prior to paying premiums cited cost as the main reason, including 20% who cited increased premiums over the previous year and 17% who claimed ineligibility for financial assistance.
Of those who activated their coverage by paying premiums, half (49%) said they stopped because they became eligible and received coverage elsewhere, mostly through an employer or Medicare. About a quarter (27%) cited affordability as the reason why they dropped coverage.
According to the Commonwealth Fund, CMS officials missed a few big reasons why people did not consistently pay for their coverage: Many were reacting to uncertainty around the Trump administration’s ACA repeal and replace efforts. Others were missed because of policy changes undertaken by the administration.
“One of the things that we know affected enrollment this year was the pullback of outreach efforts in the last weekend of the open enrollment period by the Trump administration,” Sara Collins, PhD, vice president of health care access and coverage at the Commonwealth Fund, said in an interview. “It did have an affect on enrollment and might be part of the reason why we are seeing – compared to last year – a lower effectuate enrollment.”
Other administration actions are taking a toll, Dr. Collins said.
There is a “general uncertainty that the administration is generating with respect to the enforcement of the individual mandate and also the uncertainty that is affecting insurers’ commitment to the marketplaces for 2018 [cost sharing reduction payments],” she said, noting both insurers and consumers are affected by this uncertainty.
While acknowledging that the main reason consumers dropped exchange policies was gaining coverage from source, Dr. Collins noted that “we are in such a strange environment, where it’s not clear what Congress is going to do or what the administration is going to do. It probably has confused the public somewhat about what their options are and maybe a concern even if they stay in a plan whether or not they will continue to get their tax credits. There has just been a general sense of uncertainty that has been created by the Trump administration and Congress in terms of the future of marketplace plans.”
Two reports from the Centers for Medicare & Medicaid Services show declines in the number of consumers who are activating the health insurance purchased via an Affordable Care Act exchange, a development Trump administration officials say underlines the failure of the ACA.
As of March 15, 10.3 million people paid premiums to activate coverage they purchased on the exchanges out of 12.2 million who enrolled in plans as of the Jan. 31 deadline for 2017, according to a June 12 report from CMS.
Further, some consumers who began paying premiums stopped.
Two key factors are behind the drop off, according to a second CMS report.
According to a voluntary online survey of consumers who left the exchanges between August 2016 and April 2017, 46% who canceled coverage prior to paying premiums cited cost as the main reason, including 20% who cited increased premiums over the previous year and 17% who claimed ineligibility for financial assistance.
Of those who activated their coverage by paying premiums, half (49%) said they stopped because they became eligible and received coverage elsewhere, mostly through an employer or Medicare. About a quarter (27%) cited affordability as the reason why they dropped coverage.
According to the Commonwealth Fund, CMS officials missed a few big reasons why people did not consistently pay for their coverage: Many were reacting to uncertainty around the Trump administration’s ACA repeal and replace efforts. Others were missed because of policy changes undertaken by the administration.
“One of the things that we know affected enrollment this year was the pullback of outreach efforts in the last weekend of the open enrollment period by the Trump administration,” Sara Collins, PhD, vice president of health care access and coverage at the Commonwealth Fund, said in an interview. “It did have an affect on enrollment and might be part of the reason why we are seeing – compared to last year – a lower effectuate enrollment.”
Other administration actions are taking a toll, Dr. Collins said.
There is a “general uncertainty that the administration is generating with respect to the enforcement of the individual mandate and also the uncertainty that is affecting insurers’ commitment to the marketplaces for 2018 [cost sharing reduction payments],” she said, noting both insurers and consumers are affected by this uncertainty.
While acknowledging that the main reason consumers dropped exchange policies was gaining coverage from source, Dr. Collins noted that “we are in such a strange environment, where it’s not clear what Congress is going to do or what the administration is going to do. It probably has confused the public somewhat about what their options are and maybe a concern even if they stay in a plan whether or not they will continue to get their tax credits. There has just been a general sense of uncertainty that has been created by the Trump administration and Congress in terms of the future of marketplace plans.”
Two reports from the Centers for Medicare & Medicaid Services show declines in the number of consumers who are activating the health insurance purchased via an Affordable Care Act exchange, a development Trump administration officials say underlines the failure of the ACA.
As of March 15, 10.3 million people paid premiums to activate coverage they purchased on the exchanges out of 12.2 million who enrolled in plans as of the Jan. 31 deadline for 2017, according to a June 12 report from CMS.
Further, some consumers who began paying premiums stopped.
Two key factors are behind the drop off, according to a second CMS report.
According to a voluntary online survey of consumers who left the exchanges between August 2016 and April 2017, 46% who canceled coverage prior to paying premiums cited cost as the main reason, including 20% who cited increased premiums over the previous year and 17% who claimed ineligibility for financial assistance.
Of those who activated their coverage by paying premiums, half (49%) said they stopped because they became eligible and received coverage elsewhere, mostly through an employer or Medicare. About a quarter (27%) cited affordability as the reason why they dropped coverage.
According to the Commonwealth Fund, CMS officials missed a few big reasons why people did not consistently pay for their coverage: Many were reacting to uncertainty around the Trump administration’s ACA repeal and replace efforts. Others were missed because of policy changes undertaken by the administration.
“One of the things that we know affected enrollment this year was the pullback of outreach efforts in the last weekend of the open enrollment period by the Trump administration,” Sara Collins, PhD, vice president of health care access and coverage at the Commonwealth Fund, said in an interview. “It did have an affect on enrollment and might be part of the reason why we are seeing – compared to last year – a lower effectuate enrollment.”
Other administration actions are taking a toll, Dr. Collins said.
There is a “general uncertainty that the administration is generating with respect to the enforcement of the individual mandate and also the uncertainty that is affecting insurers’ commitment to the marketplaces for 2018 [cost sharing reduction payments],” she said, noting both insurers and consumers are affected by this uncertainty.
While acknowledging that the main reason consumers dropped exchange policies was gaining coverage from source, Dr. Collins noted that “we are in such a strange environment, where it’s not clear what Congress is going to do or what the administration is going to do. It probably has confused the public somewhat about what their options are and maybe a concern even if they stay in a plan whether or not they will continue to get their tax credits. There has just been a general sense of uncertainty that has been created by the Trump administration and Congress in terms of the future of marketplace plans.”
ABIM finds 69% concordance between MOC questions and common practice
, according to new research conducted and funded by the board.
“In this study comparing the percentages of 186 categories of medical conditions seen by general internists in office visits and hospital stays with the percentages of 3,461 questions on IM-MOC examinations from 2010 to 2013, 69% of examination questions were concordant with conditions seen,” Bradley Gray, PhD, ABIM senior health services researcher, Philadelphia, and his colleagues said in a report published in JAMA (2017 Jun 13;317[22]:2317-24).
Questions’ discordance with conditions seen specifically in the office outpatient setting and in the hospital was greater. Comparing questions and office-based practice, 58% of questions (2,010) involving 145 conditions were categorized as concordant. Comparing questions and hospital stays only, 42% of questions (1,456) involving 122 conditions were categorized as concordant.
The study did not evaluate the importance of the conditions that were found in questions that were in discordance with what physicians see in practice.
“Most of the discordant conditions where the frequency of questions on the exam was greater than the frequency of conditions seen were conditions that may have been uncommon but were rated as extremely important to patient care by internists responding to a survey involving review of exam blueprints,” Marianne Green, MD, study coauthor and ABIM board member, said in a statement. “An example of this is diagnosis of vasculitis, a rare but painful condition that can slow vital blood supply to tissues and organs. Based on physicians’ input, these conditions continue to be included on the exam.”
Conversely, there are questions that appear infrequently despite the fact that they cover conditions commonly seen in practice.
“For example, the question percentage for hypertension was judged to be concordant because it was similar to hospital stay percentage (1.91% vs. 1.84%), even though the question percentage was much lower than office visit percentage for this condition (1.91% vs. 13.87%),” the authors stated in the report.
ABIM researchers added that certain common conditions do not require more questions “because care guidelines are widely disseminated and more questions in these areas may be repetitive in terms of content and, therefore, do not contribute significantly to the assessment of a physician’s clinical judgment, especially when limited testing time is available.”
The overall percentage was a reasonable range, Andrea Paul, MD, chief medical officer of BoardVitals, a New York-based company that helps doctors prepare for MOC exams, said in an interview.
“Aiming for somewhere between 65% and 75% on commonly experienced patient conditions is reasonable,” Dr. Paul said. “The reason for that is that those common things that physicians see regularly in practice are just that – they are regularly practiced. So, they don’t necessarily need as much review and testing on topics that they are maintaining their own knowledge of on a daily basis.”
It is important for maintenance of certification exams to cover the rarer conditions, compared with what doctors see regularly, she added.
“I think the exams are aiming to cover those in greater detail because, if a rare condition were to walk into someone’s practice, there would be a great lapse in reviewing those obscure or rare conditions, and it might lead to a delay in diagnosing it or a delay in treating one of those conditions,” Dr. Paul said. “While people find it a nuisance to review something they don’t see regularly, that’s the reason that it’s important.”
The study’s findings have helped inform the review of the MOC testing blueprint that began in 2015, the ABIM noted, so the results may not match the current rate of concordance between questions asked and conditions that physicians are seeing. The report’s authors added that not enough new exams have been administered and not enough information on office visits has been made available to determine the latest concordance rates.
Dr. Paul suggested that, even in internal medicine, it might be better to offer examinations that are more specialized.
“Of people taking that exam, a great proportion of them don’t practice in general outpatient internal medicine,” she said. “They are either specialized in oncology or nephrology, or they practice in academia or are researchers. So, although you would think that everyone would have what they define as a general internal medicine practice, a great proportion doesn’t practice general internal medicine, especially outpatient internal medicine.
“The way to get that [concordance] number up would be to create different maintenance of certification exams based on people’s practice type,” Dr. Paul added. “To have an exam that tests what that person’s specific area is ... That would be a way that I could see to improve it.”
All of the researchers are either employed by or affiliated with ABIM. No additional conflicts of interest were disclosed.
In recent years, ABIM examinations have placed greater emphasis on evidence-based medicine. Yet, the ABIM has been too slow to develop rigorous evidence to support the validity of its recertification examination. There will never be a perfect examination, nor will there be a perfect way to assess physician knowledge, understanding, decision making, and clinical skills.
However, the study by Gray et al. represents an important effort to provide evidence on the validity of the recertification examination and its relevance to practicing internists.
The ABIM must strive for continuous improvement and is most relevant and useful when it asks for help and listens to its members, a process that it has been involved with for the past several years. Open, ongoing evaluation of the recertification examination will be essential, along with frank and productive discussion about how to ensure the continuous improvement, excellence, and relevance of the recertification process.
Adam B. Schwartz, MD, of New York University and J. Sanford Schwartz, MD, of the University of Pennsylvania, Philadelphia, made these comments in an editorial (JAMA. 2017 Jun 13;317[22]:2288-9).
In recent years, ABIM examinations have placed greater emphasis on evidence-based medicine. Yet, the ABIM has been too slow to develop rigorous evidence to support the validity of its recertification examination. There will never be a perfect examination, nor will there be a perfect way to assess physician knowledge, understanding, decision making, and clinical skills.
However, the study by Gray et al. represents an important effort to provide evidence on the validity of the recertification examination and its relevance to practicing internists.
The ABIM must strive for continuous improvement and is most relevant and useful when it asks for help and listens to its members, a process that it has been involved with for the past several years. Open, ongoing evaluation of the recertification examination will be essential, along with frank and productive discussion about how to ensure the continuous improvement, excellence, and relevance of the recertification process.
Adam B. Schwartz, MD, of New York University and J. Sanford Schwartz, MD, of the University of Pennsylvania, Philadelphia, made these comments in an editorial (JAMA. 2017 Jun 13;317[22]:2288-9).
In recent years, ABIM examinations have placed greater emphasis on evidence-based medicine. Yet, the ABIM has been too slow to develop rigorous evidence to support the validity of its recertification examination. There will never be a perfect examination, nor will there be a perfect way to assess physician knowledge, understanding, decision making, and clinical skills.
However, the study by Gray et al. represents an important effort to provide evidence on the validity of the recertification examination and its relevance to practicing internists.
The ABIM must strive for continuous improvement and is most relevant and useful when it asks for help and listens to its members, a process that it has been involved with for the past several years. Open, ongoing evaluation of the recertification examination will be essential, along with frank and productive discussion about how to ensure the continuous improvement, excellence, and relevance of the recertification process.
Adam B. Schwartz, MD, of New York University and J. Sanford Schwartz, MD, of the University of Pennsylvania, Philadelphia, made these comments in an editorial (JAMA. 2017 Jun 13;317[22]:2288-9).
, according to new research conducted and funded by the board.
“In this study comparing the percentages of 186 categories of medical conditions seen by general internists in office visits and hospital stays with the percentages of 3,461 questions on IM-MOC examinations from 2010 to 2013, 69% of examination questions were concordant with conditions seen,” Bradley Gray, PhD, ABIM senior health services researcher, Philadelphia, and his colleagues said in a report published in JAMA (2017 Jun 13;317[22]:2317-24).
Questions’ discordance with conditions seen specifically in the office outpatient setting and in the hospital was greater. Comparing questions and office-based practice, 58% of questions (2,010) involving 145 conditions were categorized as concordant. Comparing questions and hospital stays only, 42% of questions (1,456) involving 122 conditions were categorized as concordant.
The study did not evaluate the importance of the conditions that were found in questions that were in discordance with what physicians see in practice.
“Most of the discordant conditions where the frequency of questions on the exam was greater than the frequency of conditions seen were conditions that may have been uncommon but were rated as extremely important to patient care by internists responding to a survey involving review of exam blueprints,” Marianne Green, MD, study coauthor and ABIM board member, said in a statement. “An example of this is diagnosis of vasculitis, a rare but painful condition that can slow vital blood supply to tissues and organs. Based on physicians’ input, these conditions continue to be included on the exam.”
Conversely, there are questions that appear infrequently despite the fact that they cover conditions commonly seen in practice.
“For example, the question percentage for hypertension was judged to be concordant because it was similar to hospital stay percentage (1.91% vs. 1.84%), even though the question percentage was much lower than office visit percentage for this condition (1.91% vs. 13.87%),” the authors stated in the report.
ABIM researchers added that certain common conditions do not require more questions “because care guidelines are widely disseminated and more questions in these areas may be repetitive in terms of content and, therefore, do not contribute significantly to the assessment of a physician’s clinical judgment, especially when limited testing time is available.”
The overall percentage was a reasonable range, Andrea Paul, MD, chief medical officer of BoardVitals, a New York-based company that helps doctors prepare for MOC exams, said in an interview.
“Aiming for somewhere between 65% and 75% on commonly experienced patient conditions is reasonable,” Dr. Paul said. “The reason for that is that those common things that physicians see regularly in practice are just that – they are regularly practiced. So, they don’t necessarily need as much review and testing on topics that they are maintaining their own knowledge of on a daily basis.”
It is important for maintenance of certification exams to cover the rarer conditions, compared with what doctors see regularly, she added.
“I think the exams are aiming to cover those in greater detail because, if a rare condition were to walk into someone’s practice, there would be a great lapse in reviewing those obscure or rare conditions, and it might lead to a delay in diagnosing it or a delay in treating one of those conditions,” Dr. Paul said. “While people find it a nuisance to review something they don’t see regularly, that’s the reason that it’s important.”
The study’s findings have helped inform the review of the MOC testing blueprint that began in 2015, the ABIM noted, so the results may not match the current rate of concordance between questions asked and conditions that physicians are seeing. The report’s authors added that not enough new exams have been administered and not enough information on office visits has been made available to determine the latest concordance rates.
Dr. Paul suggested that, even in internal medicine, it might be better to offer examinations that are more specialized.
“Of people taking that exam, a great proportion of them don’t practice in general outpatient internal medicine,” she said. “They are either specialized in oncology or nephrology, or they practice in academia or are researchers. So, although you would think that everyone would have what they define as a general internal medicine practice, a great proportion doesn’t practice general internal medicine, especially outpatient internal medicine.
“The way to get that [concordance] number up would be to create different maintenance of certification exams based on people’s practice type,” Dr. Paul added. “To have an exam that tests what that person’s specific area is ... That would be a way that I could see to improve it.”
All of the researchers are either employed by or affiliated with ABIM. No additional conflicts of interest were disclosed.
, according to new research conducted and funded by the board.
“In this study comparing the percentages of 186 categories of medical conditions seen by general internists in office visits and hospital stays with the percentages of 3,461 questions on IM-MOC examinations from 2010 to 2013, 69% of examination questions were concordant with conditions seen,” Bradley Gray, PhD, ABIM senior health services researcher, Philadelphia, and his colleagues said in a report published in JAMA (2017 Jun 13;317[22]:2317-24).
Questions’ discordance with conditions seen specifically in the office outpatient setting and in the hospital was greater. Comparing questions and office-based practice, 58% of questions (2,010) involving 145 conditions were categorized as concordant. Comparing questions and hospital stays only, 42% of questions (1,456) involving 122 conditions were categorized as concordant.
The study did not evaluate the importance of the conditions that were found in questions that were in discordance with what physicians see in practice.
“Most of the discordant conditions where the frequency of questions on the exam was greater than the frequency of conditions seen were conditions that may have been uncommon but were rated as extremely important to patient care by internists responding to a survey involving review of exam blueprints,” Marianne Green, MD, study coauthor and ABIM board member, said in a statement. “An example of this is diagnosis of vasculitis, a rare but painful condition that can slow vital blood supply to tissues and organs. Based on physicians’ input, these conditions continue to be included on the exam.”
Conversely, there are questions that appear infrequently despite the fact that they cover conditions commonly seen in practice.
“For example, the question percentage for hypertension was judged to be concordant because it was similar to hospital stay percentage (1.91% vs. 1.84%), even though the question percentage was much lower than office visit percentage for this condition (1.91% vs. 13.87%),” the authors stated in the report.
ABIM researchers added that certain common conditions do not require more questions “because care guidelines are widely disseminated and more questions in these areas may be repetitive in terms of content and, therefore, do not contribute significantly to the assessment of a physician’s clinical judgment, especially when limited testing time is available.”
The overall percentage was a reasonable range, Andrea Paul, MD, chief medical officer of BoardVitals, a New York-based company that helps doctors prepare for MOC exams, said in an interview.
“Aiming for somewhere between 65% and 75% on commonly experienced patient conditions is reasonable,” Dr. Paul said. “The reason for that is that those common things that physicians see regularly in practice are just that – they are regularly practiced. So, they don’t necessarily need as much review and testing on topics that they are maintaining their own knowledge of on a daily basis.”
It is important for maintenance of certification exams to cover the rarer conditions, compared with what doctors see regularly, she added.
“I think the exams are aiming to cover those in greater detail because, if a rare condition were to walk into someone’s practice, there would be a great lapse in reviewing those obscure or rare conditions, and it might lead to a delay in diagnosing it or a delay in treating one of those conditions,” Dr. Paul said. “While people find it a nuisance to review something they don’t see regularly, that’s the reason that it’s important.”
The study’s findings have helped inform the review of the MOC testing blueprint that began in 2015, the ABIM noted, so the results may not match the current rate of concordance between questions asked and conditions that physicians are seeing. The report’s authors added that not enough new exams have been administered and not enough information on office visits has been made available to determine the latest concordance rates.
Dr. Paul suggested that, even in internal medicine, it might be better to offer examinations that are more specialized.
“Of people taking that exam, a great proportion of them don’t practice in general outpatient internal medicine,” she said. “They are either specialized in oncology or nephrology, or they practice in academia or are researchers. So, although you would think that everyone would have what they define as a general internal medicine practice, a great proportion doesn’t practice general internal medicine, especially outpatient internal medicine.
“The way to get that [concordance] number up would be to create different maintenance of certification exams based on people’s practice type,” Dr. Paul added. “To have an exam that tests what that person’s specific area is ... That would be a way that I could see to improve it.”
All of the researchers are either employed by or affiliated with ABIM. No additional conflicts of interest were disclosed.
FROM JAMA
Recruiting survey notes strong demand for family physicians, psychiatrists
Family medicine continues to be the most highly recruited specialty, based on nearly 3,300 permanent physician and advanced practitioner search assignments posted from April 1, 2016, to March 31, 2017, through Merritt Hawkins’ and AMN Healthcare’s physician staffing companies.
It is the 11th consecutive year that family physicians topped the search list, and the specialty’s continued dominance is “underscoring the continued urgent demand for primary care physicians in an evolving health system,” Merritt Hawkins said in its annual report on physician recruiting.
“Primary care is increasingly the province of international medical graduates,” according to the report, which notes that U.S.-based medical students continue to show low interest in primary care because of low compensation and the perceived high level of personal time commitment required.
Demand for primary care physicians continues to grow and is likely to be exacerbated by the value-based payment models that are emerging in the wake of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the report added.
Psychiatry was the second most recruited specialty for just the second time in 24 years. The change “reflects a severe shortage of mental health professionals nationwide.”
The supply of psychiatrists is “already constrained and is soon going to diminish significantly. There currently are some 30,000 psychiatrists in active patient care in the United States, 60% of whom are 55 years or older, with many set to retire. ... With many psychiatrists aging out of the profession and with a preference among psychiatrists for outpatient practice settings, it is becoming increasingly difficult to recruit to inpatient settings.”
The top five most requested searches by medical specialty were:
- Family medicine (607), ranked first in the previous year.
- Psychiatry (256), ranked second in the previous year.
- Internal medicine (193), ranked third in the previous year.
- Nurse practitioner (137), ranked fifth in the previous year.
- Ob.gyn (109), ranked sixth in the previous year.
Family medicine continues to be the most highly recruited specialty, based on nearly 3,300 permanent physician and advanced practitioner search assignments posted from April 1, 2016, to March 31, 2017, through Merritt Hawkins’ and AMN Healthcare’s physician staffing companies.
It is the 11th consecutive year that family physicians topped the search list, and the specialty’s continued dominance is “underscoring the continued urgent demand for primary care physicians in an evolving health system,” Merritt Hawkins said in its annual report on physician recruiting.
“Primary care is increasingly the province of international medical graduates,” according to the report, which notes that U.S.-based medical students continue to show low interest in primary care because of low compensation and the perceived high level of personal time commitment required.
Demand for primary care physicians continues to grow and is likely to be exacerbated by the value-based payment models that are emerging in the wake of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the report added.
Psychiatry was the second most recruited specialty for just the second time in 24 years. The change “reflects a severe shortage of mental health professionals nationwide.”
The supply of psychiatrists is “already constrained and is soon going to diminish significantly. There currently are some 30,000 psychiatrists in active patient care in the United States, 60% of whom are 55 years or older, with many set to retire. ... With many psychiatrists aging out of the profession and with a preference among psychiatrists for outpatient practice settings, it is becoming increasingly difficult to recruit to inpatient settings.”
The top five most requested searches by medical specialty were:
- Family medicine (607), ranked first in the previous year.
- Psychiatry (256), ranked second in the previous year.
- Internal medicine (193), ranked third in the previous year.
- Nurse practitioner (137), ranked fifth in the previous year.
- Ob.gyn (109), ranked sixth in the previous year.
Family medicine continues to be the most highly recruited specialty, based on nearly 3,300 permanent physician and advanced practitioner search assignments posted from April 1, 2016, to March 31, 2017, through Merritt Hawkins’ and AMN Healthcare’s physician staffing companies.
It is the 11th consecutive year that family physicians topped the search list, and the specialty’s continued dominance is “underscoring the continued urgent demand for primary care physicians in an evolving health system,” Merritt Hawkins said in its annual report on physician recruiting.
“Primary care is increasingly the province of international medical graduates,” according to the report, which notes that U.S.-based medical students continue to show low interest in primary care because of low compensation and the perceived high level of personal time commitment required.
Demand for primary care physicians continues to grow and is likely to be exacerbated by the value-based payment models that are emerging in the wake of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the report added.
Psychiatry was the second most recruited specialty for just the second time in 24 years. The change “reflects a severe shortage of mental health professionals nationwide.”
The supply of psychiatrists is “already constrained and is soon going to diminish significantly. There currently are some 30,000 psychiatrists in active patient care in the United States, 60% of whom are 55 years or older, with many set to retire. ... With many psychiatrists aging out of the profession and with a preference among psychiatrists for outpatient practice settings, it is becoming increasingly difficult to recruit to inpatient settings.”
The top five most requested searches by medical specialty were:
- Family medicine (607), ranked first in the previous year.
- Psychiatry (256), ranked second in the previous year.
- Internal medicine (193), ranked third in the previous year.
- Nurse practitioner (137), ranked fifth in the previous year.
- Ob.gyn (109), ranked sixth in the previous year.
CBO: Demand for primary care services continues to grow
Demand for primary care services will rise by 18% between 2013 and 2023 under current law conditions, according to a report from Congressional Budget Office.
“That increase is caused primarily by growth in the size of the population,” CBO analysts said in the report. “Larger gains in health insurance coverage and more rapid aging of the population explain why the increase is expected to be larger than the 15.5% rise of the previous decade.”
While the report assumes continuation of Affordable Care Act programs, insurance coverage is the smallest component of the 18% rise, according to the CBO.
Drivers of the increase include:
- Population growth (8.7%).
- Growth in volume of care and intensity of care (4%).
- Population aging (3.2%).
- Gains in health insurance coverage (2.1%).
The analysis echoes modeling of primary care demand done by the American Academy of Family Physicians.
The CBO report does not offer a specific forecast on whether the supply of primary care physicians will meet the increased demand, but it does offer a number of policy options to increase the supply of primary care doctors.
“Such options include paying more for primary care through Medicare or Medicaid, subsidizing more residencies in primary care, helping repay loans held by medical students who agree to pursue primary care, and making it easier for foreign doctors to practice in the United States,” the report states.
Dr. Bazemore concurred with the options. “I think that is a very reasonable summary,” he said.
In particular, he noted that the payment discrepancy between primary and specialty care is a key concern when it comes to primary care shortage.
“If you have big gaps in income between subspecialists and primary care, you have more students making the former choice rather than the latter,” he said. The gap could be closed many ways, such as providing primary care bonus payments, revaluing the evaluation and management codes, blended payment models, or alternate payment models that are coming out that allow primary care providers to share in savings for improving population health.
“If you can’t narrow that gap, you won’t get more primary care physicians,” he said.
The CBO analysis is based on insurance coverage projections as of March 2016 and assumed continuation of Affordable Care Act programs. The authors noted that “changes to the ACA, including repeal or replacement, would yield different levels of insurance coverage and thus different effects on demand for primary care.”
Demand for primary care services will rise by 18% between 2013 and 2023 under current law conditions, according to a report from Congressional Budget Office.
“That increase is caused primarily by growth in the size of the population,” CBO analysts said in the report. “Larger gains in health insurance coverage and more rapid aging of the population explain why the increase is expected to be larger than the 15.5% rise of the previous decade.”
While the report assumes continuation of Affordable Care Act programs, insurance coverage is the smallest component of the 18% rise, according to the CBO.
Drivers of the increase include:
- Population growth (8.7%).
- Growth in volume of care and intensity of care (4%).
- Population aging (3.2%).
- Gains in health insurance coverage (2.1%).
The analysis echoes modeling of primary care demand done by the American Academy of Family Physicians.
The CBO report does not offer a specific forecast on whether the supply of primary care physicians will meet the increased demand, but it does offer a number of policy options to increase the supply of primary care doctors.
“Such options include paying more for primary care through Medicare or Medicaid, subsidizing more residencies in primary care, helping repay loans held by medical students who agree to pursue primary care, and making it easier for foreign doctors to practice in the United States,” the report states.
Dr. Bazemore concurred with the options. “I think that is a very reasonable summary,” he said.
In particular, he noted that the payment discrepancy between primary and specialty care is a key concern when it comes to primary care shortage.
“If you have big gaps in income between subspecialists and primary care, you have more students making the former choice rather than the latter,” he said. The gap could be closed many ways, such as providing primary care bonus payments, revaluing the evaluation and management codes, blended payment models, or alternate payment models that are coming out that allow primary care providers to share in savings for improving population health.
“If you can’t narrow that gap, you won’t get more primary care physicians,” he said.
The CBO analysis is based on insurance coverage projections as of March 2016 and assumed continuation of Affordable Care Act programs. The authors noted that “changes to the ACA, including repeal or replacement, would yield different levels of insurance coverage and thus different effects on demand for primary care.”
Demand for primary care services will rise by 18% between 2013 and 2023 under current law conditions, according to a report from Congressional Budget Office.
“That increase is caused primarily by growth in the size of the population,” CBO analysts said in the report. “Larger gains in health insurance coverage and more rapid aging of the population explain why the increase is expected to be larger than the 15.5% rise of the previous decade.”
While the report assumes continuation of Affordable Care Act programs, insurance coverage is the smallest component of the 18% rise, according to the CBO.
Drivers of the increase include:
- Population growth (8.7%).
- Growth in volume of care and intensity of care (4%).
- Population aging (3.2%).
- Gains in health insurance coverage (2.1%).
The analysis echoes modeling of primary care demand done by the American Academy of Family Physicians.
The CBO report does not offer a specific forecast on whether the supply of primary care physicians will meet the increased demand, but it does offer a number of policy options to increase the supply of primary care doctors.
“Such options include paying more for primary care through Medicare or Medicaid, subsidizing more residencies in primary care, helping repay loans held by medical students who agree to pursue primary care, and making it easier for foreign doctors to practice in the United States,” the report states.
Dr. Bazemore concurred with the options. “I think that is a very reasonable summary,” he said.
In particular, he noted that the payment discrepancy between primary and specialty care is a key concern when it comes to primary care shortage.
“If you have big gaps in income between subspecialists and primary care, you have more students making the former choice rather than the latter,” he said. The gap could be closed many ways, such as providing primary care bonus payments, revaluing the evaluation and management codes, blended payment models, or alternate payment models that are coming out that allow primary care providers to share in savings for improving population health.
“If you can’t narrow that gap, you won’t get more primary care physicians,” he said.
The CBO analysis is based on insurance coverage projections as of March 2016 and assumed continuation of Affordable Care Act programs. The authors noted that “changes to the ACA, including repeal or replacement, would yield different levels of insurance coverage and thus different effects on demand for primary care.”
