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GOP health reform: Essential health benefits, community rating under fire
Republicans are targeting two key consumer protections in their latest attempt to gain enough votes to pass the American Health Care Act, phase 1 of their Affordable Care Act repeal and replace plan.
On the chopping block are the essential health care benefits package and so-called community rating provisions – which prevent insurers from charging significantly more for older patients and those with preexisting conditions.
“Obamacare is already in a race to the bottom in terms of quality coverage for the sick and that’s because of the law’s community rating provisions, which penalize high-quality coverage for the sick,” Michael F. Cannon, director of health policy studies at the Cato Institute, said in an interview. “The [AHCA] would arguably accelerate that race to the bottom. The waiver provision in this amendment definitely would and it would because the bill would allow states to waive the community rating provisions, but only for people who were not previously insured.”
The waiver provisions would “increase premiums for the previously uninsured and discourage them from enrolling,” Mr. Cannon predicted.
David Anderson, research associate at the Margolis Center for Health Policy at Duke University, Durham, N.C., said that, if a state elects to take a waiver, so-called high-cost patients “such as individuals with cancer, individuals with cystic fibrosis, individuals with coagulation disorders, [would be] shrugged to the side into a high-cost risk pool or some kind of risk sharing ... with their own premium pool.” This could lower premium costs for healthy patients, he added.
This could be enhanced by narrowing the essential health benefits. For example, Mr. Anderson said that a state could keep the drug benefit, but apply for a waiver to narrow its coverage for all generics plus a limited list of brand names.
“Someone with cystic fibrosis with a $300,000-a-year medication will not have that covered and will be put in the high-cost risk pool,” Mr. Anderson said. “What it does is that it makes insurance cheaper for individuals who are highly unlikely to be high cost, and it makes it much more expensive for any individuals with known high-cost conditions.”
The draft amendment also would make it easier a whole lot easier to get such waivers approved: If enacted, the legislation would give default approval of such waivers and allow just 60 days for the Department of Health & Human Services to deny waiver request.
States would be able to apply for a waiver from the essential health benefits requirements for the 2020 plan year and a waiver to charge higher premiums to certain individuals for the 2019 plan year.
Waivers to change the essential health benefits package would need to meet one or more of the following conditions:
- Reduce average premiums.
- Increase enrollment.
- Stabilize the health insurance market.
- Stabilize premiums for individuals with preexisting conditions.
- Increase consumer choice.
For a state to change community rating provisions, its waiver also would need to create a mechanism, such as high-risk pools, to help those patients. Funding for these pools is provided for in the AHCA, but has been criticized as being inadequate on a national level.
Mr. Cannon of the Cato Institute predicted that such waivers ultimately would lead to more adverse selections for people needing comprehensive coverage and could force more people to lose coverage than to gain access to affordable, high-quality plans.
“If you waive essential health benefits in a community-rated market, you get even more adverse selection against comprehensive plans that sick people want, so those plans disappear,” Mr. Cannon said. “They either disappear because the insurers stop offering them or they disappear because insurers try to make the coverage worse, because Obamacare penalizes them if they don’t make coverage worse.”
He said these waivers provide little incentive for health insurers to stay in the individual markets and they could, as they are already, flee the individual markets.
The AHCA is phase 1 of the GOP repeal and replace plan. Congressional Republicans want to use the budget reconciliation process for the AHCA, so that they need only a simple majority to change revenue-generating provisions of the ACA. Phase 2 is a comprehensive review of all federal health care regulations and phase 3 is slated to be new legislation to replace the ACA with a new health care reform plan, which will require a two-thirds majority in the Senate to pass.
Republicans are targeting two key consumer protections in their latest attempt to gain enough votes to pass the American Health Care Act, phase 1 of their Affordable Care Act repeal and replace plan.
On the chopping block are the essential health care benefits package and so-called community rating provisions – which prevent insurers from charging significantly more for older patients and those with preexisting conditions.
“Obamacare is already in a race to the bottom in terms of quality coverage for the sick and that’s because of the law’s community rating provisions, which penalize high-quality coverage for the sick,” Michael F. Cannon, director of health policy studies at the Cato Institute, said in an interview. “The [AHCA] would arguably accelerate that race to the bottom. The waiver provision in this amendment definitely would and it would because the bill would allow states to waive the community rating provisions, but only for people who were not previously insured.”
The waiver provisions would “increase premiums for the previously uninsured and discourage them from enrolling,” Mr. Cannon predicted.
David Anderson, research associate at the Margolis Center for Health Policy at Duke University, Durham, N.C., said that, if a state elects to take a waiver, so-called high-cost patients “such as individuals with cancer, individuals with cystic fibrosis, individuals with coagulation disorders, [would be] shrugged to the side into a high-cost risk pool or some kind of risk sharing ... with their own premium pool.” This could lower premium costs for healthy patients, he added.
This could be enhanced by narrowing the essential health benefits. For example, Mr. Anderson said that a state could keep the drug benefit, but apply for a waiver to narrow its coverage for all generics plus a limited list of brand names.
“Someone with cystic fibrosis with a $300,000-a-year medication will not have that covered and will be put in the high-cost risk pool,” Mr. Anderson said. “What it does is that it makes insurance cheaper for individuals who are highly unlikely to be high cost, and it makes it much more expensive for any individuals with known high-cost conditions.”
The draft amendment also would make it easier a whole lot easier to get such waivers approved: If enacted, the legislation would give default approval of such waivers and allow just 60 days for the Department of Health & Human Services to deny waiver request.
States would be able to apply for a waiver from the essential health benefits requirements for the 2020 plan year and a waiver to charge higher premiums to certain individuals for the 2019 plan year.
Waivers to change the essential health benefits package would need to meet one or more of the following conditions:
- Reduce average premiums.
- Increase enrollment.
- Stabilize the health insurance market.
- Stabilize premiums for individuals with preexisting conditions.
- Increase consumer choice.
For a state to change community rating provisions, its waiver also would need to create a mechanism, such as high-risk pools, to help those patients. Funding for these pools is provided for in the AHCA, but has been criticized as being inadequate on a national level.
Mr. Cannon of the Cato Institute predicted that such waivers ultimately would lead to more adverse selections for people needing comprehensive coverage and could force more people to lose coverage than to gain access to affordable, high-quality plans.
“If you waive essential health benefits in a community-rated market, you get even more adverse selection against comprehensive plans that sick people want, so those plans disappear,” Mr. Cannon said. “They either disappear because the insurers stop offering them or they disappear because insurers try to make the coverage worse, because Obamacare penalizes them if they don’t make coverage worse.”
He said these waivers provide little incentive for health insurers to stay in the individual markets and they could, as they are already, flee the individual markets.
The AHCA is phase 1 of the GOP repeal and replace plan. Congressional Republicans want to use the budget reconciliation process for the AHCA, so that they need only a simple majority to change revenue-generating provisions of the ACA. Phase 2 is a comprehensive review of all federal health care regulations and phase 3 is slated to be new legislation to replace the ACA with a new health care reform plan, which will require a two-thirds majority in the Senate to pass.
Republicans are targeting two key consumer protections in their latest attempt to gain enough votes to pass the American Health Care Act, phase 1 of their Affordable Care Act repeal and replace plan.
On the chopping block are the essential health care benefits package and so-called community rating provisions – which prevent insurers from charging significantly more for older patients and those with preexisting conditions.
“Obamacare is already in a race to the bottom in terms of quality coverage for the sick and that’s because of the law’s community rating provisions, which penalize high-quality coverage for the sick,” Michael F. Cannon, director of health policy studies at the Cato Institute, said in an interview. “The [AHCA] would arguably accelerate that race to the bottom. The waiver provision in this amendment definitely would and it would because the bill would allow states to waive the community rating provisions, but only for people who were not previously insured.”
The waiver provisions would “increase premiums for the previously uninsured and discourage them from enrolling,” Mr. Cannon predicted.
David Anderson, research associate at the Margolis Center for Health Policy at Duke University, Durham, N.C., said that, if a state elects to take a waiver, so-called high-cost patients “such as individuals with cancer, individuals with cystic fibrosis, individuals with coagulation disorders, [would be] shrugged to the side into a high-cost risk pool or some kind of risk sharing ... with their own premium pool.” This could lower premium costs for healthy patients, he added.
This could be enhanced by narrowing the essential health benefits. For example, Mr. Anderson said that a state could keep the drug benefit, but apply for a waiver to narrow its coverage for all generics plus a limited list of brand names.
“Someone with cystic fibrosis with a $300,000-a-year medication will not have that covered and will be put in the high-cost risk pool,” Mr. Anderson said. “What it does is that it makes insurance cheaper for individuals who are highly unlikely to be high cost, and it makes it much more expensive for any individuals with known high-cost conditions.”
The draft amendment also would make it easier a whole lot easier to get such waivers approved: If enacted, the legislation would give default approval of such waivers and allow just 60 days for the Department of Health & Human Services to deny waiver request.
States would be able to apply for a waiver from the essential health benefits requirements for the 2020 plan year and a waiver to charge higher premiums to certain individuals for the 2019 plan year.
Waivers to change the essential health benefits package would need to meet one or more of the following conditions:
- Reduce average premiums.
- Increase enrollment.
- Stabilize the health insurance market.
- Stabilize premiums for individuals with preexisting conditions.
- Increase consumer choice.
For a state to change community rating provisions, its waiver also would need to create a mechanism, such as high-risk pools, to help those patients. Funding for these pools is provided for in the AHCA, but has been criticized as being inadequate on a national level.
Mr. Cannon of the Cato Institute predicted that such waivers ultimately would lead to more adverse selections for people needing comprehensive coverage and could force more people to lose coverage than to gain access to affordable, high-quality plans.
“If you waive essential health benefits in a community-rated market, you get even more adverse selection against comprehensive plans that sick people want, so those plans disappear,” Mr. Cannon said. “They either disappear because the insurers stop offering them or they disappear because insurers try to make the coverage worse, because Obamacare penalizes them if they don’t make coverage worse.”
He said these waivers provide little incentive for health insurers to stay in the individual markets and they could, as they are already, flee the individual markets.
The AHCA is phase 1 of the GOP repeal and replace plan. Congressional Republicans want to use the budget reconciliation process for the AHCA, so that they need only a simple majority to change revenue-generating provisions of the ACA. Phase 2 is a comprehensive review of all federal health care regulations and phase 3 is slated to be new legislation to replace the ACA with a new health care reform plan, which will require a two-thirds majority in the Senate to pass.
CMS market stabilization efforts useless without subsidies
New final regulations designed to bring stability to the individual health insurance market may not matter if the White House follows through on a threat to kill subsidies paid to insurers to help reduce deductibles and other out-of-pocket costs for low-income patients.
The final rule from the Centers for Medicare & Medicaid Services grants a number of wishes sought by the insurance industry to help bring a level of predictability and flexibility when designing plans for the individual market. Specifically, it does the following:
• Shortens the open enrollment period for the 2018 plan year to 6 weeks running from Nov. 1 to Dec. 15, so that open enrollment closely aligns with Medicare and other private insurance.
• Requires individuals to submit documentation when seeking coverage through a special enrollment period.
• Allows insurers to collect past-due premiums before issuing coverage for a future year.
• Provides more actuarial flexibility to allow for different plan designs.
• Returns network adequacy oversight to states.
The new rules are not expected to alter the existing market dynamic, according to Kelly Brantley, vice president at Avalere Health. 
“I would say the rule is nominally helpful, but it’s really unlikely to persuade anyone, particularly those insurers who are already on their way out. I don’t think this a game-changer for them,” she said in an interview.
The American Medical Association, in comments to the CMS when the rule was proposed as a draft, said that if finalized, the rule “would raise premiums, out-of-pocket costs, or both for millions of moderate-income families and would make it more difficult for eligible individuals to enroll in health coverage and access needed care.”
The potential impact of these regulatory changes could be moot if President Trump makes good on his threat to withhold cost-sharing subsidies to insurers. The subsides already are the subject of a lawsuit brought by the House of Representatives against the Obama administration; they continue to be paid while the suit makes its way through the judicial process. President Trump has threatened to cut off the subsidies in an effort to force Congressional Democrats to the negotiating table regarding the repeal and replacement of the Affordable Care Act.
“My take on this is that the [market stabilization] rule as written is not likely to shift the market, really, in terms of access,” Ms. Brantley said. “The bigger question is whether the cost-sharing reductions are going to be paid. I think that has a bigger likelihood of influencing issuer participation and robustness of the market in 2018.”
Even with the changes made by the market stabilization rule, “there is still too much instability and uncertainty in this market,” Marilyn Tavenner, president and CEO of the industry group America’s Health Insurance Plans, said in a statement. “Most urgently, health plans and the consumers they serve need to know that funding for cost-sharing reduction subsidies will continue uninterrupted.”
Ms. Tavenner noted that without the subsidies, more plans are likely to drop out of the health insurance exchanges, leading to premium increases, and “doctors and hospitals will see even greater strains on their ability to care for people.”
The AMA, in an April 12 letter to President Trump, cosigned by America’s Health Insurance Plans, the American Academy of Family Physicians, the American Hospital Association, the Federation of American Hospitals, the American Benefits Council, the Blue Cross Blue Shield Association, and the U.S. Chamber of Commerce, stated that the “most critical action to help stabilize the individual market for 2017 and 2018 is to remove uncertainty about continued funding for cost sharing reductions.”
Ms. Brantley added that if the subsides were cut, “it makes it more challenging to bring any kind of money back into the system at a later point. I think it would be hard for those cost-sharing reductions to go away at this point and then ever come back, but I do think that it’s a possibility that that could happen.”
The CMS released the final rule April 13, 2017, and it is scheduled for publication in the Federal Register on April 18, 2017.
New final regulations designed to bring stability to the individual health insurance market may not matter if the White House follows through on a threat to kill subsidies paid to insurers to help reduce deductibles and other out-of-pocket costs for low-income patients.
The final rule from the Centers for Medicare & Medicaid Services grants a number of wishes sought by the insurance industry to help bring a level of predictability and flexibility when designing plans for the individual market. Specifically, it does the following:
• Shortens the open enrollment period for the 2018 plan year to 6 weeks running from Nov. 1 to Dec. 15, so that open enrollment closely aligns with Medicare and other private insurance.
• Requires individuals to submit documentation when seeking coverage through a special enrollment period.
• Allows insurers to collect past-due premiums before issuing coverage for a future year.
• Provides more actuarial flexibility to allow for different plan designs.
• Returns network adequacy oversight to states.
The new rules are not expected to alter the existing market dynamic, according to Kelly Brantley, vice president at Avalere Health.
“I would say the rule is nominally helpful, but it’s really unlikely to persuade anyone, particularly those insurers who are already on their way out. I don’t think this a game-changer for them,” she said in an interview.
The American Medical Association, in comments to the CMS when the rule was proposed as a draft, said that if finalized, the rule “would raise premiums, out-of-pocket costs, or both for millions of moderate-income families and would make it more difficult for eligible individuals to enroll in health coverage and access needed care.”
The potential impact of these regulatory changes could be moot if President Trump makes good on his threat to withhold cost-sharing subsidies to insurers. The subsides already are the subject of a lawsuit brought by the House of Representatives against the Obama administration; they continue to be paid while the suit makes its way through the judicial process. President Trump has threatened to cut off the subsidies in an effort to force Congressional Democrats to the negotiating table regarding the repeal and replacement of the Affordable Care Act.
“My take on this is that the [market stabilization] rule as written is not likely to shift the market, really, in terms of access,” Ms. Brantley said. “The bigger question is whether the cost-sharing reductions are going to be paid. I think that has a bigger likelihood of influencing issuer participation and robustness of the market in 2018.”
Even with the changes made by the market stabilization rule, “there is still too much instability and uncertainty in this market,” Marilyn Tavenner, president and CEO of the industry group America’s Health Insurance Plans, said in a statement. “Most urgently, health plans and the consumers they serve need to know that funding for cost-sharing reduction subsidies will continue uninterrupted.”
Ms. Tavenner noted that without the subsidies, more plans are likely to drop out of the health insurance exchanges, leading to premium increases, and “doctors and hospitals will see even greater strains on their ability to care for people.”
The AMA, in an April 12 letter to President Trump, cosigned by America’s Health Insurance Plans, the American Academy of Family Physicians, the American Hospital Association, the Federation of American Hospitals, the American Benefits Council, the Blue Cross Blue Shield Association, and the U.S. Chamber of Commerce, stated that the “most critical action to help stabilize the individual market for 2017 and 2018 is to remove uncertainty about continued funding for cost sharing reductions.”
Ms. Brantley added that if the subsides were cut, “it makes it more challenging to bring any kind of money back into the system at a later point. I think it would be hard for those cost-sharing reductions to go away at this point and then ever come back, but I do think that it’s a possibility that that could happen.”
The CMS released the final rule April 13, 2017, and it is scheduled for publication in the Federal Register on April 18, 2017.
New final regulations designed to bring stability to the individual health insurance market may not matter if the White House follows through on a threat to kill subsidies paid to insurers to help reduce deductibles and other out-of-pocket costs for low-income patients.
The final rule from the Centers for Medicare & Medicaid Services grants a number of wishes sought by the insurance industry to help bring a level of predictability and flexibility when designing plans for the individual market. Specifically, it does the following:
• Shortens the open enrollment period for the 2018 plan year to 6 weeks running from Nov. 1 to Dec. 15, so that open enrollment closely aligns with Medicare and other private insurance.
• Requires individuals to submit documentation when seeking coverage through a special enrollment period.
• Allows insurers to collect past-due premiums before issuing coverage for a future year.
• Provides more actuarial flexibility to allow for different plan designs.
• Returns network adequacy oversight to states.
The new rules are not expected to alter the existing market dynamic, according to Kelly Brantley, vice president at Avalere Health.
“I would say the rule is nominally helpful, but it’s really unlikely to persuade anyone, particularly those insurers who are already on their way out. I don’t think this a game-changer for them,” she said in an interview.
The American Medical Association, in comments to the CMS when the rule was proposed as a draft, said that if finalized, the rule “would raise premiums, out-of-pocket costs, or both for millions of moderate-income families and would make it more difficult for eligible individuals to enroll in health coverage and access needed care.”
The potential impact of these regulatory changes could be moot if President Trump makes good on his threat to withhold cost-sharing subsidies to insurers. The subsides already are the subject of a lawsuit brought by the House of Representatives against the Obama administration; they continue to be paid while the suit makes its way through the judicial process. President Trump has threatened to cut off the subsidies in an effort to force Congressional Democrats to the negotiating table regarding the repeal and replacement of the Affordable Care Act.
“My take on this is that the [market stabilization] rule as written is not likely to shift the market, really, in terms of access,” Ms. Brantley said. “The bigger question is whether the cost-sharing reductions are going to be paid. I think that has a bigger likelihood of influencing issuer participation and robustness of the market in 2018.”
Even with the changes made by the market stabilization rule, “there is still too much instability and uncertainty in this market,” Marilyn Tavenner, president and CEO of the industry group America’s Health Insurance Plans, said in a statement. “Most urgently, health plans and the consumers they serve need to know that funding for cost-sharing reduction subsidies will continue uninterrupted.”
Ms. Tavenner noted that without the subsidies, more plans are likely to drop out of the health insurance exchanges, leading to premium increases, and “doctors and hospitals will see even greater strains on their ability to care for people.”
The AMA, in an April 12 letter to President Trump, cosigned by America’s Health Insurance Plans, the American Academy of Family Physicians, the American Hospital Association, the Federation of American Hospitals, the American Benefits Council, the Blue Cross Blue Shield Association, and the U.S. Chamber of Commerce, stated that the “most critical action to help stabilize the individual market for 2017 and 2018 is to remove uncertainty about continued funding for cost sharing reductions.”
Ms. Brantley added that if the subsides were cut, “it makes it more challenging to bring any kind of money back into the system at a later point. I think it would be hard for those cost-sharing reductions to go away at this point and then ever come back, but I do think that it’s a possibility that that could happen.”
The CMS released the final rule April 13, 2017, and it is scheduled for publication in the Federal Register on April 18, 2017.
MedPAC: Medicare Part B drug payment cuts, shared savings could save $5 billion
WASHINGTON – Reducing the amount physicians are paid for drugs administered in their offices and introducing shared savings could save Medicare up to $5 billion over 5 years, according to recommendations from the Medicare Payment Advisory Commission.
Those MedPAC recommendations to Congress include cutting physicians’ average sales price add-on percentage, as well as an alternative purchasing initiative called the Drug Value Program that would allow shared savings through more effective pharmaceutical utilization.
Physicians should not be in a position to provide Part B drugs at a financial loss, Dr. Crosson noted. But the current 6% add-on to average sales price (ASP) “overpays many physicians and institutions, and is inherently a cost-ineffecient payment system for the Medicare program,” he added.
Dr. Crosson also noted that current free market principles do not seem to be working effectively to keep drug costs down.
MedPAC’s proposal is designed to strengthen market dynamics for Part B drugs by “creating more equilibrium between the buyer and the seller than currently exists,” Dr. Crosson explained. An alternative reimbursement system will lower overall drug costs for patients while preserving quality and sharing savings with physicians, he said.
If implemented, the proposals could save Medicare between $250 million and $750 million in the first year, and between $1 billion and $5 billion within 5 years. MedPAC staff said.
All present MedPAC members (with one member not present) voted unanimously in favor of moving the two-part recommendation forward to Congress.
The first part, which would start in 2018, would alter the current Part B drug payment process. Currently, doctors receive ASP plus 6%, or wholesale acquisition cost (WAC) plus 6% for drugs without sufficient ASP history.
The proposal would enhance ASP reporting, including requiring more manufacturers to submit data and increasing fines by an unspecified amount for those that fail to meet reporting standards. The WAC add-on percentage would be reduced to 3%.
A to-be-determined inflation index would be applied to ASP and would trigger automatic rebates if ASP climbs faster than inflation. Finally, billing codes for biosimilars and their reference products would be combined.
Under the second part of MedPAC’s recommendation, in 2022 providers would face a choice: continue to have Part B drugs paid for under the ASP scheme with a reduced add-on percentage of 3%, or take part in the Drug Value Program.
Under the Drug Value Program, physicians would sign up with one of several vendors that would be charged with negotiating prices for Part B drugs. Physicians would pay the negotiated prices for the drugs. Vendors would have standard formulary tools, such as prior authorization, tiering, and step-therapy. For a very small subset of drugs with no competition in the marketplace, the proposal includes a binding arbitration process, the specific details to be determined later.
Savings generated from participating in the Drug Value Program would be shared with providers, much like other value programs that provide opportunities for shared savings in exchange for assuming a level of risk.
It was the binding-arbitration process that garnered the most concern from commission members.
“I am absolutely opposed to arbitration,” Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said. “The message that the commission is sending is that we believe in free markets, but then we don’t. The free market today would allow for many of the things that we are attempting to do with the DVP.”
She called for more detailed discussion on the arbitration process. Her concerns were echoed by other commission members. “I don’t think that arbitration ultimately results in lowering the pricing,” Ms. Bricker added, suggesting it could also open the door to collusion between DVP vendors.
The proposal will be included in MedPAC’s June 2017 report to Congress.
WASHINGTON – Reducing the amount physicians are paid for drugs administered in their offices and introducing shared savings could save Medicare up to $5 billion over 5 years, according to recommendations from the Medicare Payment Advisory Commission.
Those MedPAC recommendations to Congress include cutting physicians’ average sales price add-on percentage, as well as an alternative purchasing initiative called the Drug Value Program that would allow shared savings through more effective pharmaceutical utilization.
Physicians should not be in a position to provide Part B drugs at a financial loss, Dr. Crosson noted. But the current 6% add-on to average sales price (ASP) “overpays many physicians and institutions, and is inherently a cost-ineffecient payment system for the Medicare program,” he added.
Dr. Crosson also noted that current free market principles do not seem to be working effectively to keep drug costs down.
MedPAC’s proposal is designed to strengthen market dynamics for Part B drugs by “creating more equilibrium between the buyer and the seller than currently exists,” Dr. Crosson explained. An alternative reimbursement system will lower overall drug costs for patients while preserving quality and sharing savings with physicians, he said.
If implemented, the proposals could save Medicare between $250 million and $750 million in the first year, and between $1 billion and $5 billion within 5 years. MedPAC staff said.
All present MedPAC members (with one member not present) voted unanimously in favor of moving the two-part recommendation forward to Congress.
The first part, which would start in 2018, would alter the current Part B drug payment process. Currently, doctors receive ASP plus 6%, or wholesale acquisition cost (WAC) plus 6% for drugs without sufficient ASP history.
The proposal would enhance ASP reporting, including requiring more manufacturers to submit data and increasing fines by an unspecified amount for those that fail to meet reporting standards. The WAC add-on percentage would be reduced to 3%.
A to-be-determined inflation index would be applied to ASP and would trigger automatic rebates if ASP climbs faster than inflation. Finally, billing codes for biosimilars and their reference products would be combined.
Under the second part of MedPAC’s recommendation, in 2022 providers would face a choice: continue to have Part B drugs paid for under the ASP scheme with a reduced add-on percentage of 3%, or take part in the Drug Value Program.
Under the Drug Value Program, physicians would sign up with one of several vendors that would be charged with negotiating prices for Part B drugs. Physicians would pay the negotiated prices for the drugs. Vendors would have standard formulary tools, such as prior authorization, tiering, and step-therapy. For a very small subset of drugs with no competition in the marketplace, the proposal includes a binding arbitration process, the specific details to be determined later.
Savings generated from participating in the Drug Value Program would be shared with providers, much like other value programs that provide opportunities for shared savings in exchange for assuming a level of risk.
It was the binding-arbitration process that garnered the most concern from commission members.
“I am absolutely opposed to arbitration,” Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said. “The message that the commission is sending is that we believe in free markets, but then we don’t. The free market today would allow for many of the things that we are attempting to do with the DVP.”
She called for more detailed discussion on the arbitration process. Her concerns were echoed by other commission members. “I don’t think that arbitration ultimately results in lowering the pricing,” Ms. Bricker added, suggesting it could also open the door to collusion between DVP vendors.
The proposal will be included in MedPAC’s June 2017 report to Congress.
WASHINGTON – Reducing the amount physicians are paid for drugs administered in their offices and introducing shared savings could save Medicare up to $5 billion over 5 years, according to recommendations from the Medicare Payment Advisory Commission.
Those MedPAC recommendations to Congress include cutting physicians’ average sales price add-on percentage, as well as an alternative purchasing initiative called the Drug Value Program that would allow shared savings through more effective pharmaceutical utilization.
Physicians should not be in a position to provide Part B drugs at a financial loss, Dr. Crosson noted. But the current 6% add-on to average sales price (ASP) “overpays many physicians and institutions, and is inherently a cost-ineffecient payment system for the Medicare program,” he added.
Dr. Crosson also noted that current free market principles do not seem to be working effectively to keep drug costs down.
MedPAC’s proposal is designed to strengthen market dynamics for Part B drugs by “creating more equilibrium between the buyer and the seller than currently exists,” Dr. Crosson explained. An alternative reimbursement system will lower overall drug costs for patients while preserving quality and sharing savings with physicians, he said.
If implemented, the proposals could save Medicare between $250 million and $750 million in the first year, and between $1 billion and $5 billion within 5 years. MedPAC staff said.
All present MedPAC members (with one member not present) voted unanimously in favor of moving the two-part recommendation forward to Congress.
The first part, which would start in 2018, would alter the current Part B drug payment process. Currently, doctors receive ASP plus 6%, or wholesale acquisition cost (WAC) plus 6% for drugs without sufficient ASP history.
The proposal would enhance ASP reporting, including requiring more manufacturers to submit data and increasing fines by an unspecified amount for those that fail to meet reporting standards. The WAC add-on percentage would be reduced to 3%.
A to-be-determined inflation index would be applied to ASP and would trigger automatic rebates if ASP climbs faster than inflation. Finally, billing codes for biosimilars and their reference products would be combined.
Under the second part of MedPAC’s recommendation, in 2022 providers would face a choice: continue to have Part B drugs paid for under the ASP scheme with a reduced add-on percentage of 3%, or take part in the Drug Value Program.
Under the Drug Value Program, physicians would sign up with one of several vendors that would be charged with negotiating prices for Part B drugs. Physicians would pay the negotiated prices for the drugs. Vendors would have standard formulary tools, such as prior authorization, tiering, and step-therapy. For a very small subset of drugs with no competition in the marketplace, the proposal includes a binding arbitration process, the specific details to be determined later.
Savings generated from participating in the Drug Value Program would be shared with providers, much like other value programs that provide opportunities for shared savings in exchange for assuming a level of risk.
It was the binding-arbitration process that garnered the most concern from commission members.
“I am absolutely opposed to arbitration,” Amy Bricker, vice president of supply chain strategy at Express Scripts, St. Louis, said. “The message that the commission is sending is that we believe in free markets, but then we don’t. The free market today would allow for many of the things that we are attempting to do with the DVP.”
She called for more detailed discussion on the arbitration process. Her concerns were echoed by other commission members. “I don’t think that arbitration ultimately results in lowering the pricing,” Ms. Bricker added, suggesting it could also open the door to collusion between DVP vendors.
The proposal will be included in MedPAC’s June 2017 report to Congress.
AT MEDPAC
Report: Psychiatry workforce needs better training, delivery models
More work needs to be done to address the shortage of psychiatrists, including improvements in training and models of health care delivery, according to a new report from the National Council for Behavioral Health’s Medical Director Institute.
In framing the problem, Joseph Parks, MD, a psychiatrist who serves as medical director of the National Council, said during a March 28 teleconference to introduce the report that “55% of the counties in the United States have no psychiatrist in them” and “77% of the counties report a severe shortage.” He noted that the number of psychiatrists available declined by 10% between 2003 and 2013 and that the average age of practicing psychiatrists is in the mid-50s. In other medical specialties, the average age is in the mid-40s, he said.
“This has resulted in people having long wait times and being unable to get psychiatric services,” Dr. Parks said. Those factors are leading patients to pursue psychiatric care in alternative places, such as in primary care physician practices and emergency departments.
In emergency departments, the average wait for dispositions for some psychiatric patients can reach 23 hours, the report says. And more people are going to EDs for care.
“There has been a 42% increase in patients going to the emergency rooms for psychiatric services in the past 3 years,” Dr. Parks said. “But most of them aren’t staffed with psychiatrists. So people end up stuck in the emergency rooms for hours – two to three times as long as they spend for general medical conditions.”
The report looks at causes, and makes actionable recommendations for payers and providers. It also makes recommendations about the infrastructure needed to train future psychiatrists.
A key part of the problem is the increased demand, which is partly attributable to the expansion of health care coverage through the Affordable Care Act’s Medicaid expansion provisions as well as the normalization of views on behavioral health.
“People want psychiatric services,” said Dr. Parks, who has practiced medicine and worked as a policy maker in Missouri. “They know treatment works. It’s less stigmatized than it used to be, so people are more willing to accept and seek treatment.”
Among the trends cited by the report is a shortage of new psychiatrists coming out of medical schools.
“There are problems with not enough training capacity,” he said. “We’ve had increases in federal support for increased training capacity for ob.gyns. and primary care, but we’ve not had that same increase and support, and there are [fewer] supports for training of psychiatrists and fewer slots.”
Burnout is another problem facing psychiatrists.
“Psychiatrists who are practicing are in many cases forced to do it at lower than usual reimbursements [and] are having short visits,” Dr. Parks said. “They are rushed ... they don’t get the same supports that other physicians get. They don’t get the same ancillary staff to assist them in caring for the patients.”
Elaborating on the issues surrounding reimbursement, Dr. Parks noted that 40% of psychiatrists work on a cash-only basis, and 75% of behavioral health organizations lose money on fees collected for psychiatric services.
An ongoing workforce concern, especially in light of changes to the H-1B program, is that 50% of new trainees are foreign medical graduates.
“Luckily, there is a broad range of solutions, and there is something for all the major players to do here,” Dr. Parks said, noting that the report highlights many of these solutions.
“We need to change the care delivery system so it’s not the psychiatrist seeing everybody continuously,” he said. “Psychiatrists need to be used more as expert consultants. People need to be identified using data analytics as opposed to waiting for the patient to complain. And they need to be working more in teams, so they are doing the essential things that only a psychiatrist can do.”
Dr. Parks added that psychiatrists need to delegate “other parts of care and follow-up for people who are stable or for services that can be done by other professionals, such as psychiatric nurses or perhaps physician assistants. “We need an increase not only in more training capacity for psychiatrists but [also in] more alternative providers.”
Patrick Runnels, MD, a psychiatrist who cochairs the Medical Director Institute, highlighted several of the training issues.
“[W]e determined that psychiatrists also bear responsibility for improving this workforce crisis,” Dr. Runnels said during the call. “That starts with making our training consistent with the emerging needs and models of care that are attractive to potential trainees.”
And getting more clinicians into areas of high need, like psychiatry, starts at the medical school level.
“We were able to determine [that] in medical school, medical students were more likely to be recruited into psychiatry based on two characteristics – that the medical school had a strong reputation within their psychiatry department, particularly a strong rotation that was well rated by medical students in psychiatry, and that the length of the rotation was longer,” he said. “When those two things are put together, more students choose to go into psychiatry residency.”
In addition, more exposure is needed to aspects of practice that fit with the way in which medical care is being delivered, including better training in team-based collaborative care and medication-assisted treatment for substance use disorders.
“We also think that residents need to be placed in a range of settings, some settings in which they don’t get very much placement right now, including federally qualified health centers, patient-centered medical homes, [and] experience with telepsychiatry,” said Dr. Runnels, who also serves as medical director of the Centers for Families and Children in Cleveland.
“On top of that, we need our psychiatry residents to graduate with skills in health care data analysis, particularly at the population level,” Dr. Runnels continued. “We need our residents to understand the impact of the treatments that we have on entire populations and how to best allocate resources to deal with the whole population. Those things are hugely important.”
The National Council, based in Washington, is made up of 2,900 member organizations across the country that serve 10 million adults, children, and families who are living with mental health and substance use disorders.
More work needs to be done to address the shortage of psychiatrists, including improvements in training and models of health care delivery, according to a new report from the National Council for Behavioral Health’s Medical Director Institute.
In framing the problem, Joseph Parks, MD, a psychiatrist who serves as medical director of the National Council, said during a March 28 teleconference to introduce the report that “55% of the counties in the United States have no psychiatrist in them” and “77% of the counties report a severe shortage.” He noted that the number of psychiatrists available declined by 10% between 2003 and 2013 and that the average age of practicing psychiatrists is in the mid-50s. In other medical specialties, the average age is in the mid-40s, he said.
“This has resulted in people having long wait times and being unable to get psychiatric services,” Dr. Parks said. Those factors are leading patients to pursue psychiatric care in alternative places, such as in primary care physician practices and emergency departments.
In emergency departments, the average wait for dispositions for some psychiatric patients can reach 23 hours, the report says. And more people are going to EDs for care.
“There has been a 42% increase in patients going to the emergency rooms for psychiatric services in the past 3 years,” Dr. Parks said. “But most of them aren’t staffed with psychiatrists. So people end up stuck in the emergency rooms for hours – two to three times as long as they spend for general medical conditions.”
The report looks at causes, and makes actionable recommendations for payers and providers. It also makes recommendations about the infrastructure needed to train future psychiatrists.
A key part of the problem is the increased demand, which is partly attributable to the expansion of health care coverage through the Affordable Care Act’s Medicaid expansion provisions as well as the normalization of views on behavioral health.
“People want psychiatric services,” said Dr. Parks, who has practiced medicine and worked as a policy maker in Missouri. “They know treatment works. It’s less stigmatized than it used to be, so people are more willing to accept and seek treatment.”
Among the trends cited by the report is a shortage of new psychiatrists coming out of medical schools.
“There are problems with not enough training capacity,” he said. “We’ve had increases in federal support for increased training capacity for ob.gyns. and primary care, but we’ve not had that same increase and support, and there are [fewer] supports for training of psychiatrists and fewer slots.”
Burnout is another problem facing psychiatrists.
“Psychiatrists who are practicing are in many cases forced to do it at lower than usual reimbursements [and] are having short visits,” Dr. Parks said. “They are rushed ... they don’t get the same supports that other physicians get. They don’t get the same ancillary staff to assist them in caring for the patients.”
Elaborating on the issues surrounding reimbursement, Dr. Parks noted that 40% of psychiatrists work on a cash-only basis, and 75% of behavioral health organizations lose money on fees collected for psychiatric services.
An ongoing workforce concern, especially in light of changes to the H-1B program, is that 50% of new trainees are foreign medical graduates.
“Luckily, there is a broad range of solutions, and there is something for all the major players to do here,” Dr. Parks said, noting that the report highlights many of these solutions.
“We need to change the care delivery system so it’s not the psychiatrist seeing everybody continuously,” he said. “Psychiatrists need to be used more as expert consultants. People need to be identified using data analytics as opposed to waiting for the patient to complain. And they need to be working more in teams, so they are doing the essential things that only a psychiatrist can do.”
Dr. Parks added that psychiatrists need to delegate “other parts of care and follow-up for people who are stable or for services that can be done by other professionals, such as psychiatric nurses or perhaps physician assistants. “We need an increase not only in more training capacity for psychiatrists but [also in] more alternative providers.”
Patrick Runnels, MD, a psychiatrist who cochairs the Medical Director Institute, highlighted several of the training issues.
“[W]e determined that psychiatrists also bear responsibility for improving this workforce crisis,” Dr. Runnels said during the call. “That starts with making our training consistent with the emerging needs and models of care that are attractive to potential trainees.”
And getting more clinicians into areas of high need, like psychiatry, starts at the medical school level.
“We were able to determine [that] in medical school, medical students were more likely to be recruited into psychiatry based on two characteristics – that the medical school had a strong reputation within their psychiatry department, particularly a strong rotation that was well rated by medical students in psychiatry, and that the length of the rotation was longer,” he said. “When those two things are put together, more students choose to go into psychiatry residency.”
In addition, more exposure is needed to aspects of practice that fit with the way in which medical care is being delivered, including better training in team-based collaborative care and medication-assisted treatment for substance use disorders.
“We also think that residents need to be placed in a range of settings, some settings in which they don’t get very much placement right now, including federally qualified health centers, patient-centered medical homes, [and] experience with telepsychiatry,” said Dr. Runnels, who also serves as medical director of the Centers for Families and Children in Cleveland.
“On top of that, we need our psychiatry residents to graduate with skills in health care data analysis, particularly at the population level,” Dr. Runnels continued. “We need our residents to understand the impact of the treatments that we have on entire populations and how to best allocate resources to deal with the whole population. Those things are hugely important.”
The National Council, based in Washington, is made up of 2,900 member organizations across the country that serve 10 million adults, children, and families who are living with mental health and substance use disorders.
More work needs to be done to address the shortage of psychiatrists, including improvements in training and models of health care delivery, according to a new report from the National Council for Behavioral Health’s Medical Director Institute.
In framing the problem, Joseph Parks, MD, a psychiatrist who serves as medical director of the National Council, said during a March 28 teleconference to introduce the report that “55% of the counties in the United States have no psychiatrist in them” and “77% of the counties report a severe shortage.” He noted that the number of psychiatrists available declined by 10% between 2003 and 2013 and that the average age of practicing psychiatrists is in the mid-50s. In other medical specialties, the average age is in the mid-40s, he said.
“This has resulted in people having long wait times and being unable to get psychiatric services,” Dr. Parks said. Those factors are leading patients to pursue psychiatric care in alternative places, such as in primary care physician practices and emergency departments.
In emergency departments, the average wait for dispositions for some psychiatric patients can reach 23 hours, the report says. And more people are going to EDs for care.
“There has been a 42% increase in patients going to the emergency rooms for psychiatric services in the past 3 years,” Dr. Parks said. “But most of them aren’t staffed with psychiatrists. So people end up stuck in the emergency rooms for hours – two to three times as long as they spend for general medical conditions.”
The report looks at causes, and makes actionable recommendations for payers and providers. It also makes recommendations about the infrastructure needed to train future psychiatrists.
A key part of the problem is the increased demand, which is partly attributable to the expansion of health care coverage through the Affordable Care Act’s Medicaid expansion provisions as well as the normalization of views on behavioral health.
“People want psychiatric services,” said Dr. Parks, who has practiced medicine and worked as a policy maker in Missouri. “They know treatment works. It’s less stigmatized than it used to be, so people are more willing to accept and seek treatment.”
Among the trends cited by the report is a shortage of new psychiatrists coming out of medical schools.
“There are problems with not enough training capacity,” he said. “We’ve had increases in federal support for increased training capacity for ob.gyns. and primary care, but we’ve not had that same increase and support, and there are [fewer] supports for training of psychiatrists and fewer slots.”
Burnout is another problem facing psychiatrists.
“Psychiatrists who are practicing are in many cases forced to do it at lower than usual reimbursements [and] are having short visits,” Dr. Parks said. “They are rushed ... they don’t get the same supports that other physicians get. They don’t get the same ancillary staff to assist them in caring for the patients.”
Elaborating on the issues surrounding reimbursement, Dr. Parks noted that 40% of psychiatrists work on a cash-only basis, and 75% of behavioral health organizations lose money on fees collected for psychiatric services.
An ongoing workforce concern, especially in light of changes to the H-1B program, is that 50% of new trainees are foreign medical graduates.
“Luckily, there is a broad range of solutions, and there is something for all the major players to do here,” Dr. Parks said, noting that the report highlights many of these solutions.
“We need to change the care delivery system so it’s not the psychiatrist seeing everybody continuously,” he said. “Psychiatrists need to be used more as expert consultants. People need to be identified using data analytics as opposed to waiting for the patient to complain. And they need to be working more in teams, so they are doing the essential things that only a psychiatrist can do.”
Dr. Parks added that psychiatrists need to delegate “other parts of care and follow-up for people who are stable or for services that can be done by other professionals, such as psychiatric nurses or perhaps physician assistants. “We need an increase not only in more training capacity for psychiatrists but [also in] more alternative providers.”
Patrick Runnels, MD, a psychiatrist who cochairs the Medical Director Institute, highlighted several of the training issues.
“[W]e determined that psychiatrists also bear responsibility for improving this workforce crisis,” Dr. Runnels said during the call. “That starts with making our training consistent with the emerging needs and models of care that are attractive to potential trainees.”
And getting more clinicians into areas of high need, like psychiatry, starts at the medical school level.
“We were able to determine [that] in medical school, medical students were more likely to be recruited into psychiatry based on two characteristics – that the medical school had a strong reputation within their psychiatry department, particularly a strong rotation that was well rated by medical students in psychiatry, and that the length of the rotation was longer,” he said. “When those two things are put together, more students choose to go into psychiatry residency.”
In addition, more exposure is needed to aspects of practice that fit with the way in which medical care is being delivered, including better training in team-based collaborative care and medication-assisted treatment for substance use disorders.
“We also think that residents need to be placed in a range of settings, some settings in which they don’t get very much placement right now, including federally qualified health centers, patient-centered medical homes, [and] experience with telepsychiatry,” said Dr. Runnels, who also serves as medical director of the Centers for Families and Children in Cleveland.
“On top of that, we need our psychiatry residents to graduate with skills in health care data analysis, particularly at the population level,” Dr. Runnels continued. “We need our residents to understand the impact of the treatments that we have on entire populations and how to best allocate resources to deal with the whole population. Those things are hugely important.”
The National Council, based in Washington, is made up of 2,900 member organizations across the country that serve 10 million adults, children, and families who are living with mental health and substance use disorders.
ACGME finalizes return of trainees’ 24-hour max shift
First-year residents will once again be permitted to work up to 24 consecutive hours following a reversal of a rule implemented in 2011 that restricted them to 16 hours, the Accreditation Council for Graduate Medical Education (ACGME) announced.
According to a memo issued by the ACGME March 10, 2017, the change reverting back to the 24-hour ceiling was evidence based.
“The preponderance of the evidence from a number of studies conducted after the current 16-hour cap was implemented in 2011 suggests that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development,” the memo states. The work week is still capped at 80 hours worked per week, with 1 day free from clinical experience or education in 7, and in-house call no more frequent than every third night.
An ACGME task force determined “that the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized, and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and the effectiveness of care delivery of the team as a whole.”
Sharmila Dissanaike, MD, FACS, chair and professor of surgery at Texas Tech University, Lubbock, said in an interview that the change back to a 24-hour ceiling provides “an increased flexibility for all residents in order to allow completion of immediate patient care responsibilities, such as finishing an operation, and ensure smooth handoffs. Both of these should improve work flow for both trainees and supervisors.”
Mark A. Malangoni, MD, FACS, associate executive director of the American Board of Surgery, said he believes the change back to 24 hours is a positive thing.
“The 16-hour requirement posed a lot of scheduling problems,” he said in an interview. “In essence, what it meant was you had residents that either couldn’t take call or they did take call, it was very limited in what they could do.”
Complicating the issue of time is the nature of what needs to be taught to residents.
“What has definitely changed is the breadth of knowledge and repertoire of technical skills that must be learned by today’s residents,” Dr. Dissanaike said. “As scientific knowledge and technical capabilities expand, there is ever more to learn and increasingly less time in which to learn it.”
Dr. Malangoni added that the time restraints didn’t allow for residents to see the natural progression of the patient’s condition. “You don’t have the chance to continue to assess that over a longer period of time,” he said. “That is really important in learning when to operate on someone, but also when not to operate on someone because they will get better without an operation.”
Compounding that is a greater need for reporting to meet regulatory requirements.
“Concurrently, we have increased requirements for documentation and clerical tasks, and reduced time available to do it,” Dr. Dissanaike continued. “All of this has led to a severe ‘work-compression’ for the modern resident, and I suspect the high rates of burnout and depression that are being reported in many specialties are at least partly a result of this phenomenon.”
That being said, Dr. Dissanaike was quick to add that this latest change should not be considered a “final solution” and that there are “many ongoing issues around resident fatigue, as well as adequacy of educational experience that still need to be addressed.”
Dr. Malangoni added that residents need to be more mindful and take more responsibility for their own health and well-being.
“I think what residents need to understand is they are really in charge of their own well-being. Making that point is really a key,” he said. “So it’s not only what you do while you are in the hospital, but you are also responsible for what you do when you are not in the hospital. ACGME cannot regulate what people do in their free time. If you work a 24-hour shift and you decide you are not going to sleep the next day for whatever reason, your well-being is likely not going to be what you want it to be and what, I think, your patients want it to be.”
First-year residents will once again be permitted to work up to 24 consecutive hours following a reversal of a rule implemented in 2011 that restricted them to 16 hours, the Accreditation Council for Graduate Medical Education (ACGME) announced.
According to a memo issued by the ACGME March 10, 2017, the change reverting back to the 24-hour ceiling was evidence based.
“The preponderance of the evidence from a number of studies conducted after the current 16-hour cap was implemented in 2011 suggests that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development,” the memo states. The work week is still capped at 80 hours worked per week, with 1 day free from clinical experience or education in 7, and in-house call no more frequent than every third night.
An ACGME task force determined “that the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized, and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and the effectiveness of care delivery of the team as a whole.”
Sharmila Dissanaike, MD, FACS, chair and professor of surgery at Texas Tech University, Lubbock, said in an interview that the change back to a 24-hour ceiling provides “an increased flexibility for all residents in order to allow completion of immediate patient care responsibilities, such as finishing an operation, and ensure smooth handoffs. Both of these should improve work flow for both trainees and supervisors.”
Mark A. Malangoni, MD, FACS, associate executive director of the American Board of Surgery, said he believes the change back to 24 hours is a positive thing.
“The 16-hour requirement posed a lot of scheduling problems,” he said in an interview. “In essence, what it meant was you had residents that either couldn’t take call or they did take call, it was very limited in what they could do.”
Complicating the issue of time is the nature of what needs to be taught to residents.
“What has definitely changed is the breadth of knowledge and repertoire of technical skills that must be learned by today’s residents,” Dr. Dissanaike said. “As scientific knowledge and technical capabilities expand, there is ever more to learn and increasingly less time in which to learn it.”
Dr. Malangoni added that the time restraints didn’t allow for residents to see the natural progression of the patient’s condition. “You don’t have the chance to continue to assess that over a longer period of time,” he said. “That is really important in learning when to operate on someone, but also when not to operate on someone because they will get better without an operation.”
Compounding that is a greater need for reporting to meet regulatory requirements.
“Concurrently, we have increased requirements for documentation and clerical tasks, and reduced time available to do it,” Dr. Dissanaike continued. “All of this has led to a severe ‘work-compression’ for the modern resident, and I suspect the high rates of burnout and depression that are being reported in many specialties are at least partly a result of this phenomenon.”
That being said, Dr. Dissanaike was quick to add that this latest change should not be considered a “final solution” and that there are “many ongoing issues around resident fatigue, as well as adequacy of educational experience that still need to be addressed.”
Dr. Malangoni added that residents need to be more mindful and take more responsibility for their own health and well-being.
“I think what residents need to understand is they are really in charge of their own well-being. Making that point is really a key,” he said. “So it’s not only what you do while you are in the hospital, but you are also responsible for what you do when you are not in the hospital. ACGME cannot regulate what people do in their free time. If you work a 24-hour shift and you decide you are not going to sleep the next day for whatever reason, your well-being is likely not going to be what you want it to be and what, I think, your patients want it to be.”
First-year residents will once again be permitted to work up to 24 consecutive hours following a reversal of a rule implemented in 2011 that restricted them to 16 hours, the Accreditation Council for Graduate Medical Education (ACGME) announced.
According to a memo issued by the ACGME March 10, 2017, the change reverting back to the 24-hour ceiling was evidence based.
“The preponderance of the evidence from a number of studies conducted after the current 16-hour cap was implemented in 2011 suggests that it may not have had an incremental benefit in patient safety, and that there might be significant negative impacts to the quality of physician education and professional development,” the memo states. The work week is still capped at 80 hours worked per week, with 1 day free from clinical experience or education in 7, and in-house call no more frequent than every third night.
An ACGME task force determined “that the hypothesized benefits associated with the changes made to first-year resident scheduled hours in 2011 have not been realized, and the disruption of team-based care and supervisory systems has had a significant negative impact on the professional education of the first-year resident, and the effectiveness of care delivery of the team as a whole.”
Sharmila Dissanaike, MD, FACS, chair and professor of surgery at Texas Tech University, Lubbock, said in an interview that the change back to a 24-hour ceiling provides “an increased flexibility for all residents in order to allow completion of immediate patient care responsibilities, such as finishing an operation, and ensure smooth handoffs. Both of these should improve work flow for both trainees and supervisors.”
Mark A. Malangoni, MD, FACS, associate executive director of the American Board of Surgery, said he believes the change back to 24 hours is a positive thing.
“The 16-hour requirement posed a lot of scheduling problems,” he said in an interview. “In essence, what it meant was you had residents that either couldn’t take call or they did take call, it was very limited in what they could do.”
Complicating the issue of time is the nature of what needs to be taught to residents.
“What has definitely changed is the breadth of knowledge and repertoire of technical skills that must be learned by today’s residents,” Dr. Dissanaike said. “As scientific knowledge and technical capabilities expand, there is ever more to learn and increasingly less time in which to learn it.”
Dr. Malangoni added that the time restraints didn’t allow for residents to see the natural progression of the patient’s condition. “You don’t have the chance to continue to assess that over a longer period of time,” he said. “That is really important in learning when to operate on someone, but also when not to operate on someone because they will get better without an operation.”
Compounding that is a greater need for reporting to meet regulatory requirements.
“Concurrently, we have increased requirements for documentation and clerical tasks, and reduced time available to do it,” Dr. Dissanaike continued. “All of this has led to a severe ‘work-compression’ for the modern resident, and I suspect the high rates of burnout and depression that are being reported in many specialties are at least partly a result of this phenomenon.”
That being said, Dr. Dissanaike was quick to add that this latest change should not be considered a “final solution” and that there are “many ongoing issues around resident fatigue, as well as adequacy of educational experience that still need to be addressed.”
Dr. Malangoni added that residents need to be more mindful and take more responsibility for their own health and well-being.
“I think what residents need to understand is they are really in charge of their own well-being. Making that point is really a key,” he said. “So it’s not only what you do while you are in the hospital, but you are also responsible for what you do when you are not in the hospital. ACGME cannot regulate what people do in their free time. If you work a 24-hour shift and you decide you are not going to sleep the next day for whatever reason, your well-being is likely not going to be what you want it to be and what, I think, your patients want it to be.”
OpenNotes: Patient engagement with low physician hassle
ORLANDO – Early evidence suggests that OpenNotes is helping to engage patients and improve health outcomes while not creating undue burden for physicians.
A 2010 pilot project at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle tested OpenNotes, a program that allows patients to see the entirety of a physician’s notes within their medical record and not just a summarized version.
Homer Chin, MD, of the department of medical informatics and outcomes research at Oregon Health & Science University, Portland, an associate with the OpenNotes Program, and physician champion for the Northwest OpenNotes Consortium, noted that a survey of the 105 primary care physicians participating in the pilot revealed they were apprehensive when they heard their visit notes would be completely available to patients.
Prior to the launch of the pilot, 24% of physicians expected significantly longer visits because of the availability of OpenNotes, 42% said they expected to spend more time addressing patient questions outside of visits, and 39% said they expected to spend more time writing/editing/dictating notes, Dr. Chin said at the annual meeting of the Healthcare Information and Management Systems Society.
Their concerns never quite materialized.
According to a survey of the participating physicians after the yearlong pilot, only 2% reported visits took significantly longer, 3% said they spent more time addressing patient questions outside of visits, and 11% said they spent more time writing/editing/dictating notes.
With regard to writing notes, “what we are finding is that most physicians are saying they are changing the way they write the note a little bit, but it is not taking more time,” Dr. Chin said. “They are just watching for certain terms and writing them in a different way, but it is not necessarily taking more time.”
More than 70% of patients who participated in the trial reported they are taking better care of themselves, more than 77% said they have a better understanding of their medical condition, more than 69% said they are better prepared for visits and more than 60% said they are more adherent to their prescription medication regimens.
Importantly, 85% said the availability of OpenNotes would affect their future choice of providers.
Dr. Chin also discussed the results of a survey of patients using OpenNotes in the Virginia Commonwealth University Health System in Richmond, noting that of roughly 420 respondents, 70% said their contact with their providers did not change, with nearly 20% saying they were contacting their provider less. Just over 40% said that reading their notes made them less worried about something health related, while a little more than 50% said there was no change. Nearly 85% said they thought seeing the notes helped them take better care of themselves. Nearly 90% of patients said that they understood some or all of their doctors’ notes.
It has been incredibly valuable “when the patients use the portal to prepare themselves for the visit with the provider,” Mr. Kravitz said. “They will review their case. They’ll look at past x-rays or reports, any kind of information, the results for laboratory and anything else, but they will message their provider. They are very heavy into messaging. It’s secure messaging within the portal and any type of questions, especially after they’ve had an appointment, they’ve thought of something they didn’t think about in the appointment, they have the opportunity to message back to the provider’s office.”
Geisinger saw 620,000 encounter reviews in OpenNotes out of 2 million patient visits in its last fiscal year, with virtually no complaints about the information in the OpenNotes.
Dr. Chin stressed that the implemented OpenNotes needs to be driven by physicians.
“I would emphasize that this has to be a clinician operational leader supported effort, and not an IT effort, so that when clinicians complain, you can point them to their department head, the chief medical officer, and not the IT people,” he said. “You’ve got to have good communication to providers. Our advice is to start with one department. You might do a pilot for a very short period of time, but there is enough evidence now to really implement it throughout the organization. We encourage people not to allow individual providers to opt out on their own, to make their own decision to opt out, to do it as an organizational effort.”
Michael Day, chief information officer of Ascension Health and Columbia St. Mary’s Health System of Milwaukee, offered the same advice.
“You’ve got to have leadership commitment up front,” Mr. Day said. “This really has to have good, strong physician leadership. The key executive in charge of all of this was the president of our medical group which drove a lot of the change with a lot of support from other areas.”
He noted that at his organization there was “a lot of physician grumbling” when OpenNotes was announced. However, there has been “relatively no impact. I think they’ve all agreed that this has made care better. We’ve also seen an actual improvement in the quality of the documentation.”
None of the presenters reported any conflicts of interest.
ORLANDO – Early evidence suggests that OpenNotes is helping to engage patients and improve health outcomes while not creating undue burden for physicians.
A 2010 pilot project at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle tested OpenNotes, a program that allows patients to see the entirety of a physician’s notes within their medical record and not just a summarized version.
Homer Chin, MD, of the department of medical informatics and outcomes research at Oregon Health & Science University, Portland, an associate with the OpenNotes Program, and physician champion for the Northwest OpenNotes Consortium, noted that a survey of the 105 primary care physicians participating in the pilot revealed they were apprehensive when they heard their visit notes would be completely available to patients.
Prior to the launch of the pilot, 24% of physicians expected significantly longer visits because of the availability of OpenNotes, 42% said they expected to spend more time addressing patient questions outside of visits, and 39% said they expected to spend more time writing/editing/dictating notes, Dr. Chin said at the annual meeting of the Healthcare Information and Management Systems Society.
Their concerns never quite materialized.
According to a survey of the participating physicians after the yearlong pilot, only 2% reported visits took significantly longer, 3% said they spent more time addressing patient questions outside of visits, and 11% said they spent more time writing/editing/dictating notes.
With regard to writing notes, “what we are finding is that most physicians are saying they are changing the way they write the note a little bit, but it is not taking more time,” Dr. Chin said. “They are just watching for certain terms and writing them in a different way, but it is not necessarily taking more time.”
More than 70% of patients who participated in the trial reported they are taking better care of themselves, more than 77% said they have a better understanding of their medical condition, more than 69% said they are better prepared for visits and more than 60% said they are more adherent to their prescription medication regimens.
Importantly, 85% said the availability of OpenNotes would affect their future choice of providers.
Dr. Chin also discussed the results of a survey of patients using OpenNotes in the Virginia Commonwealth University Health System in Richmond, noting that of roughly 420 respondents, 70% said their contact with their providers did not change, with nearly 20% saying they were contacting their provider less. Just over 40% said that reading their notes made them less worried about something health related, while a little more than 50% said there was no change. Nearly 85% said they thought seeing the notes helped them take better care of themselves. Nearly 90% of patients said that they understood some or all of their doctors’ notes.
It has been incredibly valuable “when the patients use the portal to prepare themselves for the visit with the provider,” Mr. Kravitz said. “They will review their case. They’ll look at past x-rays or reports, any kind of information, the results for laboratory and anything else, but they will message their provider. They are very heavy into messaging. It’s secure messaging within the portal and any type of questions, especially after they’ve had an appointment, they’ve thought of something they didn’t think about in the appointment, they have the opportunity to message back to the provider’s office.”
Geisinger saw 620,000 encounter reviews in OpenNotes out of 2 million patient visits in its last fiscal year, with virtually no complaints about the information in the OpenNotes.
Dr. Chin stressed that the implemented OpenNotes needs to be driven by physicians.
“I would emphasize that this has to be a clinician operational leader supported effort, and not an IT effort, so that when clinicians complain, you can point them to their department head, the chief medical officer, and not the IT people,” he said. “You’ve got to have good communication to providers. Our advice is to start with one department. You might do a pilot for a very short period of time, but there is enough evidence now to really implement it throughout the organization. We encourage people not to allow individual providers to opt out on their own, to make their own decision to opt out, to do it as an organizational effort.”
Michael Day, chief information officer of Ascension Health and Columbia St. Mary’s Health System of Milwaukee, offered the same advice.
“You’ve got to have leadership commitment up front,” Mr. Day said. “This really has to have good, strong physician leadership. The key executive in charge of all of this was the president of our medical group which drove a lot of the change with a lot of support from other areas.”
He noted that at his organization there was “a lot of physician grumbling” when OpenNotes was announced. However, there has been “relatively no impact. I think they’ve all agreed that this has made care better. We’ve also seen an actual improvement in the quality of the documentation.”
None of the presenters reported any conflicts of interest.
ORLANDO – Early evidence suggests that OpenNotes is helping to engage patients and improve health outcomes while not creating undue burden for physicians.
A 2010 pilot project at Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Pennsylvania, and Harborview Medical Center in Seattle tested OpenNotes, a program that allows patients to see the entirety of a physician’s notes within their medical record and not just a summarized version.
Homer Chin, MD, of the department of medical informatics and outcomes research at Oregon Health & Science University, Portland, an associate with the OpenNotes Program, and physician champion for the Northwest OpenNotes Consortium, noted that a survey of the 105 primary care physicians participating in the pilot revealed they were apprehensive when they heard their visit notes would be completely available to patients.
Prior to the launch of the pilot, 24% of physicians expected significantly longer visits because of the availability of OpenNotes, 42% said they expected to spend more time addressing patient questions outside of visits, and 39% said they expected to spend more time writing/editing/dictating notes, Dr. Chin said at the annual meeting of the Healthcare Information and Management Systems Society.
Their concerns never quite materialized.
According to a survey of the participating physicians after the yearlong pilot, only 2% reported visits took significantly longer, 3% said they spent more time addressing patient questions outside of visits, and 11% said they spent more time writing/editing/dictating notes.
With regard to writing notes, “what we are finding is that most physicians are saying they are changing the way they write the note a little bit, but it is not taking more time,” Dr. Chin said. “They are just watching for certain terms and writing them in a different way, but it is not necessarily taking more time.”
More than 70% of patients who participated in the trial reported they are taking better care of themselves, more than 77% said they have a better understanding of their medical condition, more than 69% said they are better prepared for visits and more than 60% said they are more adherent to their prescription medication regimens.
Importantly, 85% said the availability of OpenNotes would affect their future choice of providers.
Dr. Chin also discussed the results of a survey of patients using OpenNotes in the Virginia Commonwealth University Health System in Richmond, noting that of roughly 420 respondents, 70% said their contact with their providers did not change, with nearly 20% saying they were contacting their provider less. Just over 40% said that reading their notes made them less worried about something health related, while a little more than 50% said there was no change. Nearly 85% said they thought seeing the notes helped them take better care of themselves. Nearly 90% of patients said that they understood some or all of their doctors’ notes.
It has been incredibly valuable “when the patients use the portal to prepare themselves for the visit with the provider,” Mr. Kravitz said. “They will review their case. They’ll look at past x-rays or reports, any kind of information, the results for laboratory and anything else, but they will message their provider. They are very heavy into messaging. It’s secure messaging within the portal and any type of questions, especially after they’ve had an appointment, they’ve thought of something they didn’t think about in the appointment, they have the opportunity to message back to the provider’s office.”
Geisinger saw 620,000 encounter reviews in OpenNotes out of 2 million patient visits in its last fiscal year, with virtually no complaints about the information in the OpenNotes.
Dr. Chin stressed that the implemented OpenNotes needs to be driven by physicians.
“I would emphasize that this has to be a clinician operational leader supported effort, and not an IT effort, so that when clinicians complain, you can point them to their department head, the chief medical officer, and not the IT people,” he said. “You’ve got to have good communication to providers. Our advice is to start with one department. You might do a pilot for a very short period of time, but there is enough evidence now to really implement it throughout the organization. We encourage people not to allow individual providers to opt out on their own, to make their own decision to opt out, to do it as an organizational effort.”
Michael Day, chief information officer of Ascension Health and Columbia St. Mary’s Health System of Milwaukee, offered the same advice.
“You’ve got to have leadership commitment up front,” Mr. Day said. “This really has to have good, strong physician leadership. The key executive in charge of all of this was the president of our medical group which drove a lot of the change with a lot of support from other areas.”
He noted that at his organization there was “a lot of physician grumbling” when OpenNotes was announced. However, there has been “relatively no impact. I think they’ve all agreed that this has made care better. We’ve also seen an actual improvement in the quality of the documentation.”
None of the presenters reported any conflicts of interest.
AT HIMSS 2017
Match Day: Surgery positions up, other specialties grew more
Despite a record number of applicants and slots filled for first-year residents on the 2017 Match Day, growth in all surgery positions continued to be outpaced by growth in other specialties.
“While it is encouraging to see that the number of categorical surgery positions offered has increased by 101 since 2013, representing an increase of 8.6%, over the same period, the number of positions offered in emergency medicine and family medicine positions have each increased by over 300, representing increases of 17.4% and 11.5%, respectively, and the number of internal medicine positions has increased by over 900, representing an increase of 15.2%,” Patrick Bailey, MD, FACS, medical director of advocacy for the Division of Advocacy and Health Policy at the American College of Surgeons. “The fact that over 35,969 applicants submitted program choices and only 27,688 matched into a PGY-1 position is yet another indication of the need to expand the number of graduate medical education positions available,” he added.
And while more positions may be needed, the number of categorical surgery positions that went unfilled remained low, with only 5 of 1,281 slots remaining unfilled at the conclusion of Match Day 2017, according to the data released by the National Resident Match Program (NRMP).
“This result is consistent with those since 2013 during which time the number of unfilled positions has varied between two and seven positions, e.g., 99.4%-99.8% of categorical surgery positions offered were filled,” Dr. Bailey said.
Still, the ACS is advocating for further changes to the resident matching program to help build the future workforce. “The ACS believes broad reforms in the way graduate medical education is funded and administered are necessary and overdue to ensure that our nation is able to produce the physician workforce capable of meeting the needs of the U.S. population,” he said. To that end, the ACS produced a policy paper that outlined a series of steps relative to reform for which it is advocating.
Broadly, those reforms include the collection of actionable and accurate health care workforce data, maintenance of current GME funding levels with the appropriation of temporary additional funds to modernize the system, the combination of the current GME funding streams into a single stream of funds, and the consideration of a regionalized governance system.
Overall, this is the fifth straight year the NRMP has reported growth in applicants, up 1.4% from the previous year, and applicants matched, to PGY-1 positions up 3.2% from 2016.
One factor driving the increase is the “all-in” policy that required programs registering for the Match to offer all their available positions in the Match or another national matching program. The policy, which began with the 2013 Match, has resulted in significant increases for internal medicine, family medicine, and pediatrics.
Internal medicine residency programs offered 7,233 programs, accounting for about 25% of all PGY-1 positions. This was up from 7,024 programs offered last year. U.S. seniors accounted for 44.9% of the 7,101 slots filled, a rate that was slightly lower than the 46.9% of slots filled by U.S. medical school graduates in 2016.
A record-high 18,539 allopathic medical school seniors submitted program choices and 17,480 (94.3%) were matched to first-year resident programs, a rate that has been consistent for a number of years according to NRMP data.
Of the 1,279 unfilled slots, 1,177 were offered in the Match Week Supplemental Offer and Acceptance Program, the results of which will be available in May.
One trend that stood out for NRMP President and CEO Mona Signer was the decline in both U.S.- and non–U.S.-citizen international medical school graduates (IMGs) who submitted program choices.
“I was surprised that the number of U.S.-citizen and non–U.S.-citizen IMGs declined this year, but on the other hand, the good news is their match rates went up,” Ms. Signer said in an interview.
U.S.-citizen IMGs declined by 254 to 5,069, but 54.8% were matched to first-year residency positions, the highest match rate since 2004. The number of non–U.S.-citizen IMGs declined by 176 to 7,284, but 52.4% were matched to first-year positions, the highest match rate since 2005.
Ms. Signer declined to speculate what caused the decline, noting that NRMP does not collect demographic data.
Despite a record number of applicants and slots filled for first-year residents on the 2017 Match Day, growth in all surgery positions continued to be outpaced by growth in other specialties.
“While it is encouraging to see that the number of categorical surgery positions offered has increased by 101 since 2013, representing an increase of 8.6%, over the same period, the number of positions offered in emergency medicine and family medicine positions have each increased by over 300, representing increases of 17.4% and 11.5%, respectively, and the number of internal medicine positions has increased by over 900, representing an increase of 15.2%,” Patrick Bailey, MD, FACS, medical director of advocacy for the Division of Advocacy and Health Policy at the American College of Surgeons. “The fact that over 35,969 applicants submitted program choices and only 27,688 matched into a PGY-1 position is yet another indication of the need to expand the number of graduate medical education positions available,” he added.
And while more positions may be needed, the number of categorical surgery positions that went unfilled remained low, with only 5 of 1,281 slots remaining unfilled at the conclusion of Match Day 2017, according to the data released by the National Resident Match Program (NRMP).
“This result is consistent with those since 2013 during which time the number of unfilled positions has varied between two and seven positions, e.g., 99.4%-99.8% of categorical surgery positions offered were filled,” Dr. Bailey said.
Still, the ACS is advocating for further changes to the resident matching program to help build the future workforce. “The ACS believes broad reforms in the way graduate medical education is funded and administered are necessary and overdue to ensure that our nation is able to produce the physician workforce capable of meeting the needs of the U.S. population,” he said. To that end, the ACS produced a policy paper that outlined a series of steps relative to reform for which it is advocating.
Broadly, those reforms include the collection of actionable and accurate health care workforce data, maintenance of current GME funding levels with the appropriation of temporary additional funds to modernize the system, the combination of the current GME funding streams into a single stream of funds, and the consideration of a regionalized governance system.
Overall, this is the fifth straight year the NRMP has reported growth in applicants, up 1.4% from the previous year, and applicants matched, to PGY-1 positions up 3.2% from 2016.
One factor driving the increase is the “all-in” policy that required programs registering for the Match to offer all their available positions in the Match or another national matching program. The policy, which began with the 2013 Match, has resulted in significant increases for internal medicine, family medicine, and pediatrics.
Internal medicine residency programs offered 7,233 programs, accounting for about 25% of all PGY-1 positions. This was up from 7,024 programs offered last year. U.S. seniors accounted for 44.9% of the 7,101 slots filled, a rate that was slightly lower than the 46.9% of slots filled by U.S. medical school graduates in 2016.
A record-high 18,539 allopathic medical school seniors submitted program choices and 17,480 (94.3%) were matched to first-year resident programs, a rate that has been consistent for a number of years according to NRMP data.
Of the 1,279 unfilled slots, 1,177 were offered in the Match Week Supplemental Offer and Acceptance Program, the results of which will be available in May.
One trend that stood out for NRMP President and CEO Mona Signer was the decline in both U.S.- and non–U.S.-citizen international medical school graduates (IMGs) who submitted program choices.
“I was surprised that the number of U.S.-citizen and non–U.S.-citizen IMGs declined this year, but on the other hand, the good news is their match rates went up,” Ms. Signer said in an interview.
U.S.-citizen IMGs declined by 254 to 5,069, but 54.8% were matched to first-year residency positions, the highest match rate since 2004. The number of non–U.S.-citizen IMGs declined by 176 to 7,284, but 52.4% were matched to first-year positions, the highest match rate since 2005.
Ms. Signer declined to speculate what caused the decline, noting that NRMP does not collect demographic data.
Despite a record number of applicants and slots filled for first-year residents on the 2017 Match Day, growth in all surgery positions continued to be outpaced by growth in other specialties.
“While it is encouraging to see that the number of categorical surgery positions offered has increased by 101 since 2013, representing an increase of 8.6%, over the same period, the number of positions offered in emergency medicine and family medicine positions have each increased by over 300, representing increases of 17.4% and 11.5%, respectively, and the number of internal medicine positions has increased by over 900, representing an increase of 15.2%,” Patrick Bailey, MD, FACS, medical director of advocacy for the Division of Advocacy and Health Policy at the American College of Surgeons. “The fact that over 35,969 applicants submitted program choices and only 27,688 matched into a PGY-1 position is yet another indication of the need to expand the number of graduate medical education positions available,” he added.
And while more positions may be needed, the number of categorical surgery positions that went unfilled remained low, with only 5 of 1,281 slots remaining unfilled at the conclusion of Match Day 2017, according to the data released by the National Resident Match Program (NRMP).
“This result is consistent with those since 2013 during which time the number of unfilled positions has varied between two and seven positions, e.g., 99.4%-99.8% of categorical surgery positions offered were filled,” Dr. Bailey said.
Still, the ACS is advocating for further changes to the resident matching program to help build the future workforce. “The ACS believes broad reforms in the way graduate medical education is funded and administered are necessary and overdue to ensure that our nation is able to produce the physician workforce capable of meeting the needs of the U.S. population,” he said. To that end, the ACS produced a policy paper that outlined a series of steps relative to reform for which it is advocating.
Broadly, those reforms include the collection of actionable and accurate health care workforce data, maintenance of current GME funding levels with the appropriation of temporary additional funds to modernize the system, the combination of the current GME funding streams into a single stream of funds, and the consideration of a regionalized governance system.
Overall, this is the fifth straight year the NRMP has reported growth in applicants, up 1.4% from the previous year, and applicants matched, to PGY-1 positions up 3.2% from 2016.
One factor driving the increase is the “all-in” policy that required programs registering for the Match to offer all their available positions in the Match or another national matching program. The policy, which began with the 2013 Match, has resulted in significant increases for internal medicine, family medicine, and pediatrics.
Internal medicine residency programs offered 7,233 programs, accounting for about 25% of all PGY-1 positions. This was up from 7,024 programs offered last year. U.S. seniors accounted for 44.9% of the 7,101 slots filled, a rate that was slightly lower than the 46.9% of slots filled by U.S. medical school graduates in 2016.
A record-high 18,539 allopathic medical school seniors submitted program choices and 17,480 (94.3%) were matched to first-year resident programs, a rate that has been consistent for a number of years according to NRMP data.
Of the 1,279 unfilled slots, 1,177 were offered in the Match Week Supplemental Offer and Acceptance Program, the results of which will be available in May.
One trend that stood out for NRMP President and CEO Mona Signer was the decline in both U.S.- and non–U.S.-citizen international medical school graduates (IMGs) who submitted program choices.
“I was surprised that the number of U.S.-citizen and non–U.S.-citizen IMGs declined this year, but on the other hand, the good news is their match rates went up,” Ms. Signer said in an interview.
U.S.-citizen IMGs declined by 254 to 5,069, but 54.8% were matched to first-year residency positions, the highest match rate since 2004. The number of non–U.S.-citizen IMGs declined by 176 to 7,284, but 52.4% were matched to first-year positions, the highest match rate since 2005.
Ms. Signer declined to speculate what caused the decline, noting that NRMP does not collect demographic data.
GOP health plan clears first hurdle; opposition lines up
The Republican plan to replace the Affordable Care Act cleared the first legislative hurdle when two house committees passed language that would repeal revenue provisions of the Affordable Care Act and lay the foundation for replacing the health care reform law.
The House Ways and Means Committee–approved legislation would eliminate the individual mandate in favor of allowing insurance companies to penalize individuals by up to 30% of premiums for lapses in coverage and would repeal taxes on high-cost health plans (Cadillac tax), over-the-counter and prescription medications, health savings accounts, tanning, investment, and on health insurers.
The language passed with a party-line vote March 9 with 23 Republicans voting for and 16 Democrats voting against after nearly 18 hours of debate and amendments.
The House Energy and Commerce Committee, after 27 hours of debate that started March 8, also passed its language along party lines with 31 Republicans voting for and 23 Democrats voting against. Their bill would end Medicaid expansion and reset the program’s funding to a per capita allotment based on population indicators, along with block grants, to provide states more flexibility to better manage its population.
In both committees, Democrats introduced a wide range of amendments, including guarantees there would be no impact from the reduction of Medicaid expansion and on funding to support coverage for mental health, women, children, seniors, and veterans, all of which were voted down. Ways and Means members also offered an amendment to require President Trump to release his income tax filings.
Rep. Frank Pallone (D-N.J.), lead Democrat on the Energy and Commerce Committee, voiced his colleagues’ objections to the bill and the process. The bill “would rip health care away from millions of Americans, raise costs for working families and seniors, and lead to the rationing of care for 76 million Americans who receive Medicaid.
The pace of action in the House even drew criticism from some in the GOP. Sen. Tom Cotton (R-Ark.) took to Twitter with a stern warning to the House. “House health-care bill can’t pass w/o major changes,” Sen. Cotton tweeted. “To my friends in House: pause, start over. Get it right, don’t get it fast.”
He followed up with two more tweets: “GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed. With no budget estimate!” He added: “What matters in long run is better, more affordable health care for Americans, NOT house leaders’ arbitrary legislative calendar.”
Four Republican senators – Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.), and Lisa Murkowski (Alaska) – also expressed concerns regarding how Medicaid will be changed under the repeal/replace effort and vowed not to support any plan “that does not include stability for Medicaid expansion populations or flexibility for states.”
Republicans hold a slim 52-seat majority in the Senate and need only 50 votes to pass any legislation that uses the budget reconciliation process. If those four senators voted with Democrats, who are expected to vote as a party against the repeal effort, the current House Republican legislation would not clear the Senate.
Physicians’ groups also have voiced their opposition. American Medical Association President Andrew Gurman, MD, said in a statement that it is “not legislation we can support. The replacement bill, as written, would reverse the coverage gains of the ACA, causing many Americans to lose the health coverage they have come to depend on.” He added that the proposed changes to Medicaid “would limit states’ ability to respond to changes in service demands and threaten coverage for people with low incomes.”
Likewise, a joint statement issued by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association, expressed concern that the proposal “will likely result in less access to coverage and higher costs for millions of patients.”
AGA is closely monitoring the process to ensure that patients are still able to receive coverage for preventive screenings without cost-sharing, such as colorectal cancer screenings, and they continue to advocate that this section remain. They are concerned that patients will not have access to specialty care. A repeal will result in millions of patients being uninsured and millions of dollars in uncompensated care to providers like gastroenterologists. AGA will continue to monitor the legislative process and voice its concerns. Learn more about how you can get involved through the AGA Political Action Committee.
The Republican plan to replace the Affordable Care Act cleared the first legislative hurdle when two house committees passed language that would repeal revenue provisions of the Affordable Care Act and lay the foundation for replacing the health care reform law.
The House Ways and Means Committee–approved legislation would eliminate the individual mandate in favor of allowing insurance companies to penalize individuals by up to 30% of premiums for lapses in coverage and would repeal taxes on high-cost health plans (Cadillac tax), over-the-counter and prescription medications, health savings accounts, tanning, investment, and on health insurers.
The language passed with a party-line vote March 9 with 23 Republicans voting for and 16 Democrats voting against after nearly 18 hours of debate and amendments.
The House Energy and Commerce Committee, after 27 hours of debate that started March 8, also passed its language along party lines with 31 Republicans voting for and 23 Democrats voting against. Their bill would end Medicaid expansion and reset the program’s funding to a per capita allotment based on population indicators, along with block grants, to provide states more flexibility to better manage its population.
In both committees, Democrats introduced a wide range of amendments, including guarantees there would be no impact from the reduction of Medicaid expansion and on funding to support coverage for mental health, women, children, seniors, and veterans, all of which were voted down. Ways and Means members also offered an amendment to require President Trump to release his income tax filings.
Rep. Frank Pallone (D-N.J.), lead Democrat on the Energy and Commerce Committee, voiced his colleagues’ objections to the bill and the process. The bill “would rip health care away from millions of Americans, raise costs for working families and seniors, and lead to the rationing of care for 76 million Americans who receive Medicaid.
The pace of action in the House even drew criticism from some in the GOP. Sen. Tom Cotton (R-Ark.) took to Twitter with a stern warning to the House. “House health-care bill can’t pass w/o major changes,” Sen. Cotton tweeted. “To my friends in House: pause, start over. Get it right, don’t get it fast.”
He followed up with two more tweets: “GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed. With no budget estimate!” He added: “What matters in long run is better, more affordable health care for Americans, NOT house leaders’ arbitrary legislative calendar.”
Four Republican senators – Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.), and Lisa Murkowski (Alaska) – also expressed concerns regarding how Medicaid will be changed under the repeal/replace effort and vowed not to support any plan “that does not include stability for Medicaid expansion populations or flexibility for states.”
Republicans hold a slim 52-seat majority in the Senate and need only 50 votes to pass any legislation that uses the budget reconciliation process. If those four senators voted with Democrats, who are expected to vote as a party against the repeal effort, the current House Republican legislation would not clear the Senate.
Physicians’ groups also have voiced their opposition. American Medical Association President Andrew Gurman, MD, said in a statement that it is “not legislation we can support. The replacement bill, as written, would reverse the coverage gains of the ACA, causing many Americans to lose the health coverage they have come to depend on.” He added that the proposed changes to Medicaid “would limit states’ ability to respond to changes in service demands and threaten coverage for people with low incomes.”
Likewise, a joint statement issued by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association, expressed concern that the proposal “will likely result in less access to coverage and higher costs for millions of patients.”
AGA is closely monitoring the process to ensure that patients are still able to receive coverage for preventive screenings without cost-sharing, such as colorectal cancer screenings, and they continue to advocate that this section remain. They are concerned that patients will not have access to specialty care. A repeal will result in millions of patients being uninsured and millions of dollars in uncompensated care to providers like gastroenterologists. AGA will continue to monitor the legislative process and voice its concerns. Learn more about how you can get involved through the AGA Political Action Committee.
The Republican plan to replace the Affordable Care Act cleared the first legislative hurdle when two house committees passed language that would repeal revenue provisions of the Affordable Care Act and lay the foundation for replacing the health care reform law.
The House Ways and Means Committee–approved legislation would eliminate the individual mandate in favor of allowing insurance companies to penalize individuals by up to 30% of premiums for lapses in coverage and would repeal taxes on high-cost health plans (Cadillac tax), over-the-counter and prescription medications, health savings accounts, tanning, investment, and on health insurers.
The language passed with a party-line vote March 9 with 23 Republicans voting for and 16 Democrats voting against after nearly 18 hours of debate and amendments.
The House Energy and Commerce Committee, after 27 hours of debate that started March 8, also passed its language along party lines with 31 Republicans voting for and 23 Democrats voting against. Their bill would end Medicaid expansion and reset the program’s funding to a per capita allotment based on population indicators, along with block grants, to provide states more flexibility to better manage its population.
In both committees, Democrats introduced a wide range of amendments, including guarantees there would be no impact from the reduction of Medicaid expansion and on funding to support coverage for mental health, women, children, seniors, and veterans, all of which were voted down. Ways and Means members also offered an amendment to require President Trump to release his income tax filings.
Rep. Frank Pallone (D-N.J.), lead Democrat on the Energy and Commerce Committee, voiced his colleagues’ objections to the bill and the process. The bill “would rip health care away from millions of Americans, raise costs for working families and seniors, and lead to the rationing of care for 76 million Americans who receive Medicaid.
The pace of action in the House even drew criticism from some in the GOP. Sen. Tom Cotton (R-Ark.) took to Twitter with a stern warning to the House. “House health-care bill can’t pass w/o major changes,” Sen. Cotton tweeted. “To my friends in House: pause, start over. Get it right, don’t get it fast.”
He followed up with two more tweets: “GOP shouldn’t act like Dems did in O’care. No excuse to release bill Mon night, start voting Wed. With no budget estimate!” He added: “What matters in long run is better, more affordable health care for Americans, NOT house leaders’ arbitrary legislative calendar.”
Four Republican senators – Rob Portman (Ohio), Shelley Moore Capito (W.Va.), Cory Gardner (Colo.), and Lisa Murkowski (Alaska) – also expressed concerns regarding how Medicaid will be changed under the repeal/replace effort and vowed not to support any plan “that does not include stability for Medicaid expansion populations or flexibility for states.”
Republicans hold a slim 52-seat majority in the Senate and need only 50 votes to pass any legislation that uses the budget reconciliation process. If those four senators voted with Democrats, who are expected to vote as a party against the repeal effort, the current House Republican legislation would not clear the Senate.
Physicians’ groups also have voiced their opposition. American Medical Association President Andrew Gurman, MD, said in a statement that it is “not legislation we can support. The replacement bill, as written, would reverse the coverage gains of the ACA, causing many Americans to lose the health coverage they have come to depend on.” He added that the proposed changes to Medicaid “would limit states’ ability to respond to changes in service demands and threaten coverage for people with low incomes.”
Likewise, a joint statement issued by the American Academy of Family Physicians, American Academy of Pediatricians, American College of Physicians, American Congress of Obstetricians and Gynecologists and the American Osteopathic Association, expressed concern that the proposal “will likely result in less access to coverage and higher costs for millions of patients.”
AGA is closely monitoring the process to ensure that patients are still able to receive coverage for preventive screenings without cost-sharing, such as colorectal cancer screenings, and they continue to advocate that this section remain. They are concerned that patients will not have access to specialty care. A repeal will result in millions of patients being uninsured and millions of dollars in uncompensated care to providers like gastroenterologists. AGA will continue to monitor the legislative process and voice its concerns. Learn more about how you can get involved through the AGA Political Action Committee.
Loss of global periods could mean $1 billion loss for dermatologists
Failing to report on global period codes this year could lead to payment changes that would cost dermatologists a collective $1 billion.
Presently, surgical procedures and follow-up visits are paid by Medicare as a single bundled payment, with the expectation that the follow-ups will occur within a 10- or 90-day period. CMS tried to eliminate these global period codes in 2014, but Congress stepped in and, as part of passage of the MACRA reform law, required the agency to study the effects of such a shift.
Whether this test will demonstrate clearly just how much dermatologists rely on global periods to cover the services they render remains to be seen.
The required reporting is resource intensive and onerous, Murad Alam, MD, of Northwestern University, Chicago, said in an interview. “No one’s really going to report them.”
“I think its definitely not going to be successful in capturing the data needed to keep the global period,” he said, adding that dermatologists alone could lose more than $1 billion if global periods were eliminated.
CMS wants to understand when follow-up visits happen. It is asking providers in those nine states to submit CPT code 99024 for each follow-up visit related to a surgical procedure and will be looking for the follow-up visit code linked to procedures reported by 100 or more physicians, that have 10,000 or more occurrences, or that have allowed charges of more than $10 million annually. The extent to which the CPT code is reported could impact whether global periods are maintained.
“The way [the test] was developed was – I would hate to think by intent but certainly by design even if not intent – it’s going to necessarily result in significant underreporting, which will inevitably result in the conclusion that … the global periods will go away,” Dr. Alam said.
One possible solution would be to simply subtract the value of the follow-up visits from the global period payments and pay them separately, but Dr. Alam said that paying them separately would not necessarily provide equal levels of payment.
“If you subtract the value of the level two follow-up visits from that code, you don’t get where you need to be,” he said. “In some cases, you actually end up with negative values for codes.”
Plus, it would take a while to properly value the codes for the follow-up visits following a surgery, particularly for those following surgical procedures in dermatology, as they tend to be resource intensive, he said.
And that does not factor into the equation the additional administrative burden of filing claims for each individual follow-up visit.
The loss of global-period billing could be huge for dermatologists, and it could cause more economic disruption than the other MACRA-based reforms, according Clifford W. Lober, MD.
“If we were to lose our global periods, it would impact us far more than [the Merit-based Incentive Payment System] will,” said Dr. Lober, a dermatologist in Kissimmee, Fla. “The worst case under MIPS will be a 9% reduction in payments several years from now. We stand to lose significantly more than 9%, particularly from highly surgical practices, if we were to lose our global periods.”
Eliminating global-period billing also could mean higher out-of-pocket costs for patients, Dr. Lober said. “If patients have pay a [copayment] when they return for surgical follow-up visits, they simply may elect not to show up.”
Failing to report on global period codes this year could lead to payment changes that would cost dermatologists a collective $1 billion.
Presently, surgical procedures and follow-up visits are paid by Medicare as a single bundled payment, with the expectation that the follow-ups will occur within a 10- or 90-day period. CMS tried to eliminate these global period codes in 2014, but Congress stepped in and, as part of passage of the MACRA reform law, required the agency to study the effects of such a shift.
Whether this test will demonstrate clearly just how much dermatologists rely on global periods to cover the services they render remains to be seen.
The required reporting is resource intensive and onerous, Murad Alam, MD, of Northwestern University, Chicago, said in an interview. “No one’s really going to report them.”
“I think its definitely not going to be successful in capturing the data needed to keep the global period,” he said, adding that dermatologists alone could lose more than $1 billion if global periods were eliminated.
CMS wants to understand when follow-up visits happen. It is asking providers in those nine states to submit CPT code 99024 for each follow-up visit related to a surgical procedure and will be looking for the follow-up visit code linked to procedures reported by 100 or more physicians, that have 10,000 or more occurrences, or that have allowed charges of more than $10 million annually. The extent to which the CPT code is reported could impact whether global periods are maintained.
“The way [the test] was developed was – I would hate to think by intent but certainly by design even if not intent – it’s going to necessarily result in significant underreporting, which will inevitably result in the conclusion that … the global periods will go away,” Dr. Alam said.
One possible solution would be to simply subtract the value of the follow-up visits from the global period payments and pay them separately, but Dr. Alam said that paying them separately would not necessarily provide equal levels of payment.
“If you subtract the value of the level two follow-up visits from that code, you don’t get where you need to be,” he said. “In some cases, you actually end up with negative values for codes.”
Plus, it would take a while to properly value the codes for the follow-up visits following a surgery, particularly for those following surgical procedures in dermatology, as they tend to be resource intensive, he said.
And that does not factor into the equation the additional administrative burden of filing claims for each individual follow-up visit.
The loss of global-period billing could be huge for dermatologists, and it could cause more economic disruption than the other MACRA-based reforms, according Clifford W. Lober, MD.
“If we were to lose our global periods, it would impact us far more than [the Merit-based Incentive Payment System] will,” said Dr. Lober, a dermatologist in Kissimmee, Fla. “The worst case under MIPS will be a 9% reduction in payments several years from now. We stand to lose significantly more than 9%, particularly from highly surgical practices, if we were to lose our global periods.”
Eliminating global-period billing also could mean higher out-of-pocket costs for patients, Dr. Lober said. “If patients have pay a [copayment] when they return for surgical follow-up visits, they simply may elect not to show up.”
Failing to report on global period codes this year could lead to payment changes that would cost dermatologists a collective $1 billion.
Presently, surgical procedures and follow-up visits are paid by Medicare as a single bundled payment, with the expectation that the follow-ups will occur within a 10- or 90-day period. CMS tried to eliminate these global period codes in 2014, but Congress stepped in and, as part of passage of the MACRA reform law, required the agency to study the effects of such a shift.
Whether this test will demonstrate clearly just how much dermatologists rely on global periods to cover the services they render remains to be seen.
The required reporting is resource intensive and onerous, Murad Alam, MD, of Northwestern University, Chicago, said in an interview. “No one’s really going to report them.”
“I think its definitely not going to be successful in capturing the data needed to keep the global period,” he said, adding that dermatologists alone could lose more than $1 billion if global periods were eliminated.
CMS wants to understand when follow-up visits happen. It is asking providers in those nine states to submit CPT code 99024 for each follow-up visit related to a surgical procedure and will be looking for the follow-up visit code linked to procedures reported by 100 or more physicians, that have 10,000 or more occurrences, or that have allowed charges of more than $10 million annually. The extent to which the CPT code is reported could impact whether global periods are maintained.
“The way [the test] was developed was – I would hate to think by intent but certainly by design even if not intent – it’s going to necessarily result in significant underreporting, which will inevitably result in the conclusion that … the global periods will go away,” Dr. Alam said.
One possible solution would be to simply subtract the value of the follow-up visits from the global period payments and pay them separately, but Dr. Alam said that paying them separately would not necessarily provide equal levels of payment.
“If you subtract the value of the level two follow-up visits from that code, you don’t get where you need to be,” he said. “In some cases, you actually end up with negative values for codes.”
Plus, it would take a while to properly value the codes for the follow-up visits following a surgery, particularly for those following surgical procedures in dermatology, as they tend to be resource intensive, he said.
And that does not factor into the equation the additional administrative burden of filing claims for each individual follow-up visit.
The loss of global-period billing could be huge for dermatologists, and it could cause more economic disruption than the other MACRA-based reforms, according Clifford W. Lober, MD.
“If we were to lose our global periods, it would impact us far more than [the Merit-based Incentive Payment System] will,” said Dr. Lober, a dermatologist in Kissimmee, Fla. “The worst case under MIPS will be a 9% reduction in payments several years from now. We stand to lose significantly more than 9%, particularly from highly surgical practices, if we were to lose our global periods.”
Eliminating global-period billing also could mean higher out-of-pocket costs for patients, Dr. Lober said. “If patients have pay a [copayment] when they return for surgical follow-up visits, they simply may elect not to show up.”
CMS delays start of cardiac pay bundles
The Centers for Medicare & Medicaid Services is delaying the start of three cardiac payment bundles finalized at the end of 2016.
The bundles include the Acute Myocardial Infarction (AMI) model, the Coronary Artery Bypass Graft (CABG) model, and the Cardiac Rehabilitation Incentive Payment model.
The payment bundles were schedule to go into effect on July 1, 2017, but an interim final rule published March 21 in the Federal Register delayed the start of the bundles for 3 months. The agency also is seeking comment on potentially delaying implementation of the bundles to Jan. 1, 2018.
The bundled payment models would place accountability for patient outcomes 90 days after discharge on the hospital where treatment occurred. Hospitals in 98 randomly selected metropolitan statistical areas would be placed in this model and monitored for 5 years to test whether the models lead to improved outcomes and lower costs.
For the cardiac rehabilitation model, CMS would be testing whether an incentive payment would increase the use of cardiac rehabilitation services during a care period that runs parallel with the AMI and CABG payment bundles.
Physician participation in the bundles would have been voluntary, but those participating would have been eligible for bonus payments under the Quality Payment Program as the bundles were considered advanced Alternative Payment Models.
The final rule also delays changes to the comprehensive joint replacement bundle.
CMS had announced the final rule implementing the payment bundles on Dec. 20, 2016, but it was not published in the Federal Register until Jan. 3, 2017. The March 21 interim final rule delaying the start of the bundles cites the Trump administration’s memorandum to federal agencies freezing in-process regulations to allow for review.
The Centers for Medicare & Medicaid Services is delaying the start of three cardiac payment bundles finalized at the end of 2016.
The bundles include the Acute Myocardial Infarction (AMI) model, the Coronary Artery Bypass Graft (CABG) model, and the Cardiac Rehabilitation Incentive Payment model.
The payment bundles were schedule to go into effect on July 1, 2017, but an interim final rule published March 21 in the Federal Register delayed the start of the bundles for 3 months. The agency also is seeking comment on potentially delaying implementation of the bundles to Jan. 1, 2018.
The bundled payment models would place accountability for patient outcomes 90 days after discharge on the hospital where treatment occurred. Hospitals in 98 randomly selected metropolitan statistical areas would be placed in this model and monitored for 5 years to test whether the models lead to improved outcomes and lower costs.
For the cardiac rehabilitation model, CMS would be testing whether an incentive payment would increase the use of cardiac rehabilitation services during a care period that runs parallel with the AMI and CABG payment bundles.
Physician participation in the bundles would have been voluntary, but those participating would have been eligible for bonus payments under the Quality Payment Program as the bundles were considered advanced Alternative Payment Models.
The final rule also delays changes to the comprehensive joint replacement bundle.
CMS had announced the final rule implementing the payment bundles on Dec. 20, 2016, but it was not published in the Federal Register until Jan. 3, 2017. The March 21 interim final rule delaying the start of the bundles cites the Trump administration’s memorandum to federal agencies freezing in-process regulations to allow for review.
The Centers for Medicare & Medicaid Services is delaying the start of three cardiac payment bundles finalized at the end of 2016.
The bundles include the Acute Myocardial Infarction (AMI) model, the Coronary Artery Bypass Graft (CABG) model, and the Cardiac Rehabilitation Incentive Payment model.
The payment bundles were schedule to go into effect on July 1, 2017, but an interim final rule published March 21 in the Federal Register delayed the start of the bundles for 3 months. The agency also is seeking comment on potentially delaying implementation of the bundles to Jan. 1, 2018.
The bundled payment models would place accountability for patient outcomes 90 days after discharge on the hospital where treatment occurred. Hospitals in 98 randomly selected metropolitan statistical areas would be placed in this model and monitored for 5 years to test whether the models lead to improved outcomes and lower costs.
For the cardiac rehabilitation model, CMS would be testing whether an incentive payment would increase the use of cardiac rehabilitation services during a care period that runs parallel with the AMI and CABG payment bundles.
Physician participation in the bundles would have been voluntary, but those participating would have been eligible for bonus payments under the Quality Payment Program as the bundles were considered advanced Alternative Payment Models.
The final rule also delays changes to the comprehensive joint replacement bundle.
CMS had announced the final rule implementing the payment bundles on Dec. 20, 2016, but it was not published in the Federal Register until Jan. 3, 2017. The March 21 interim final rule delaying the start of the bundles cites the Trump administration’s memorandum to federal agencies freezing in-process regulations to allow for review.