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Top Story: CMA blasts CMS for approving Medi-Cal
rate cuts
In what will prove to be a huge roadblock for health care reform implementation in California, the Centers for Medicare & Medicaid Services on Thursday approved the state's request to slash Medi-Cal payment rates by 10 percent.
Also in this issue:
- Independent study finds Medi-Cal patients' access to
health care limited - Palmetto conducting audits of physician claims
- CMS releases final, more physician-friendly rules for Medicare ACOs
- Final reminder: Tomorrow is deadline to apply for e-prescribing exemption
- FAQ: How do I comply with patient requests to restrict disclosures to a health plan?
- 2010 Medicare quality reporting feedback reports now available
- Have you established an Injury and Illness Prevention Program as required by law?
- Performance art and swing band are big hits at the CMA Crystal Gala
- The 2011 Nye Award given to San Francisco psychiatrist, David Pating, M.D.
- CMS proposes regulatory reforms that could save health care providers nearly $1.1 billion
- Board highlights now available
- Upcoming webinars:
Featured member benefits:
Rental Cars: California Medical Association members can save up to 15 percent on car rentals from Avis and Hertz. Members-only codes are needed to take advantage of these discounts.
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1. CMA blasts CMS for approving Medi-Cal rate cuts
In what will prove to be a huge roadblock for health care reform implementation in California, the Centers for Medicare & Medicaid Services (CMS) on Thursday approved the state's request to slash Medi-Cal payment rates by 10 percent.
The cuts approved by CMS include:
- A 10 percent provider payment reduction on a number of outpatient services, including physicians, clinics, optometrists, therapists, laboratories, dental, durable medical equipment and pharmacy.
- A 10 percent provider payment reduction for freestanding nursing and adult subacute facilities.
- A 10 percent provider payment reduction and rate freeze for distinct part/nursing facility-B services.
Exempt from the cuts are physician and clinic services for children, outpatient hospital care, home health services and subacute nursing facility services for adults. Cuts will also not apply to any services that are enjoined by lawsuits. CMS has yet to rule on California's other requested cuts, which include $5 copayments for physician visits, $50 copayments for emergency department visits and a cap of seven office visits per year.
California's Medi-Cal rates are already almost the lowest in the nation. Currently, half the doctors in the state cannot afford to participate in the program. The gaping hole in the safety net will be further exacerbated as there will be 3 million uninsured newly eligible for Medi-Cal in 2014 under the federal health reform legislation.
"The President built his expansion of access to care on the Medi-Cal system and with this decision his administration has effectively destroyed it," says Dustin Corcoran, CEO of the California Medical Association (CMA). "Adding three million patients to Medi-Cal while reducing physician resources is nothing but a recipe for disaster."
Federal law requires that Medicaid (Medi-Cal in California) patients have the same access to physicians and other health care providers as the general insured public. CMA strongly believes that even before these cuts California is in violation of federal access law.
An independent study recently commissioned by CMA found that 49 percent of Medi-Cal patients are unable to get health care when they need it, compared to just 26 percent of privately insured patients.
Just last week, CMA filed a petition with CMS asking that corrective action be taken to address current reimbursement rates and access standards. "CMS has chosen to ignore its own law with this decision," says Corcoran.
"What we’re seeing now, is that Medi-Cal patients are already having a tough time getting access to care," says CMA President James T. Hay, M.D. "With these cuts, physicians will only be reimbursed $11 per Medi-Cal patient visit, when it costs the physician several times that to provide. Physicians will be forced to reduce the number of Medi-Cal patients they accept, if they can continue to see any at all. We want to be able to treat these patients and we regret that the federal government is making it impossible."
Recent data from the California Office of Statewide Health Planning and Development, compiled by the American College of Emergency Physicians, shows that emergency room use by Medi-Cal patients increased 30 percent between 2007 and 2009 (most recent reporting period). This demonstrates that Medi-Cal beneficiaries are already being forced to seek necessary care in the ER when they can’t find a physician.
"The approval of provider payment reductions will ensure overcrowding in emergency rooms and will absolutely mean less access to care for all Californians," Corcoran adds. "Of course these are tough budget times, but the Department of Health Care Services and CMS are balancing their budgets on the backs of the most vulnerable Californians."
According to CMS, California "submitted extensive data demonstrating that the remaining cuts will not jeopardize Californian’s access to care and has agreed to ongoing monitoring of access to care for the affected services." CMA is extremely disappointed in the secretive process and that this data was not shared with providers and other stakeholders.
CMA and others made repeated requests for such data to support the state's claim that the cuts will not negatively affect access to care for Medi-Cal patients. DHCS's failure to provide the requested data prompted CMA and the California Pharmacists Association to take joint legal action earlier this month under the California Public Records Act.
CMA is extremely angry with CMS for approving these cuts in light of the overwhelming access to care problems in the state’s Medi-Cal program. The cuts will unquestionably cause irreparable harm to patients by forcing physicians out of the Medi-Cal program.
CMA will continue to fight at all levels to ensure that California's most vulnerable patients receive the care that they need. To help CMA in this fight, we need your help. Please take a few minutes to complete a brief survey.
Contact: Elizabeth McNeil, (415) 882-3376 or emcneil@cmanet.org.
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2. Independent study finds Medi-Cal patients' access to health care limited
An independent study commissioned by the California Medical Association (CMA) found that 36 percent of Medi-Cal enrollees said they were unable to see a doctor because the provider did not participate in Medi-Cal. That is four times the number of privately-insured Californians who were turned down by doctors due to their insurance carrier (9 percent).
“Data presented in this survey shows that patients’ needs aren’t being met with the current system,” says CMA CEO Dustin Corcoran. “Despite the proposed cuts that have been submitted by the Department Health Care Services (DHCS) to the Centers for Medicare & Medicaid Services (CMS), the program is already in violation of federal law. Access to care must be equal for Medi-Cal and privately insured patients and the facts are here—they’re simply not.”
Key findings of the survey as reported by the independent pollster include:
- There are significant disparities in health status and access to primary care between Medi-Cal patients and other Californians.
- When Medi-Cal patients needed health care, only half received it, compared to nearly 75 percent of privately insured patients.
- Medi-Cal patients are far more likely than other Californians to be turned down by a physician who would not accept their insurance.
- Medi-Cal patients are more than four times more likely to get care in a hospital emergency room because they could not get an appointment with a doctor or clinic.
The survey was conducted after DHCS, which administers the Medi-Cal program, asked CMS for permission to reduce Medi-Cal reimbursements by 10 percent, limit patient visits and impose mandatory patient copayments.
“California needs to prepare for an infusion of 2 to 3 million more Californians in the Medi-Cal program in the next couple of years,” says Corcoran. “We need to ensure there will be enough doctors participating in the program to ensure Medi-Cal patients have access to quality care and don’t turn to an expensive emergency room setting for routine care. Continued inadequate payments will undermine the successful expansion of Medi-Cal.”
The survey was conducted by the Sacramento firm of Fairbank, Maslin, Maullin, Metz & Associates in late August. Researchers spoke by phone with 763 Californians—363 with Medi-Cal and 400 who received health care from other sources.
A full survey summary is available here.
Contact: Molly Weedn, (916) 551-2069 or mweedn@cmanet.org.
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3. Palmetto conducting audits of physician claims
For the past two years Palmetto GBA has received payment error rates from the Comprehensive Error Rate Testing (CERT) Contractor that have been almost twice the national rate. A large portion of the errors are attributed to insufficient and illegible documentation, and lack of or illegible signatures. Palmetto is now taking steps to correct these errors by reviewing claims to identify potential areas for provider education.
Palmetto will notify affected physicians by mail that a small sample of their claims will be selected for medical review. The notice will also provide recommended resources on documentation and coding. Physicians who are notified will receive a request for medical records in the form of an Additional Document Request (ADR) for each claim selected, along with an example of the information that should be returned. Failure to respond to these requests will result in non-payment of the claim.
Palmetto may also call or make unannounced site visits to physician offices to schedule an appointment for an educational meeting. Failure to participate in this education will result in 100 percent pre- and post-payment audit of claims. CMA is discussing the nature of these audits with Palmetto and the disruption and burden they will be to physician offices.
For more information on this and other Medicare audits, see CMA’s Medicare Audit Guide for Physicians. This guide is available free to members in CMA’s online resource library.
CMA will provide more information as it becomes available.
Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.
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4. CMS releases final, more physician-friendly rules for Medicare ACOs
Responding to complaints from the California Medical Association (CMA), American Medical Association and others in organized medicine, the Centers for Medicare & Medicaid Services (CMS) released a final version of its Medicare accountable care organization (ACO) regulations that seeks to be more physician-friendly.
Although CMA has generally been supportive of the ACO concept, the draft regulations issued earlier this year were burdensome and complicated and would have made ACO participation either impossible or unattractive for both large medical groups and small independent practices.
In June of this year, CMA urged CMS to modify several unworkable provisions of its proposed regulations, including the requirement that physicians accept financial risk. The earlier version of the regulations proposed a two-track system that would have required ACOs to repay any expenditures above the target benchmark. After preliminary review, it appears that the final rule includes a number of positive changes that may make it more attractive for California physicians to participate in ACOs.
In the final regulation, ACOs will be allowed to share in savings beginning with the first dollar of savings earned. While there will still be two different ACO tracks, one will be “upside only” during the three-year contract period, i.e., the ACO will not be liable to pay CMS if expenditures exceed the ACO’s spending benchmark. The second track will give ACOs a larger share of the savings if they also agree to share in the losses.
Other improvements include: a reduction in the number of quality measures from 65 to 33; elimination of the Hospital Acquired Conditions measures; removal of the requirement that 50 percent of an ACO’s primary care physicians need to be “meaningful users” of electronic health records; and a slight improvement to the beneficiary assignment process.
Most significant, CMS has created a complementary program through the Innovation Center to provide “advance payments” to physician organizations and rural providers that do not have the capital reserves available to finance the formation of an ACO or to cover short-term losses while waiting to receive shared savings payments.
CMA is still reviewing the regulations and will provide additional details.
The final regulation is available from the Office of the Federal Register.
Contact: Francisco Silva, (916) 444-5532 or fsilva@cmanet.org.
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5. Final reminder: Tomorrow is deadline to apply for e-prescribing exemption
The Centers for Medicare & Medicaid Services (CMS) recently issued a final rule that makes several significant changes to the 2011 Medicare e-prescribing initiative. Among the changes is a one month extension to the deadline to apply for a hardship exemption. Physicians now have until November 1 to file for an exemption.
The final rule requires physicians in individual practices to have submitted at least 10 Medicare Part B claims with the electronic measure code eRx G8553 and an eligible encounter code by June 30, 2011. Physicians who failed to do so will see their 2012 Medicare payments reduced by 1 percent, unless they fall into one of the six new exemption categories:
- Physician’s practice is located in a rural area without high speed internet access.
- Physician’s practice is located in an area without sufficient available pharmacies for electronic prescribing.
- Physician is registered to participate in the Medicare or Medicaid electronic health record incentive (EHR) program and has adopted certified EHR technology.
- Physician is unable to electronically prescribe due to local, state or federal law or regulation (e.g., prescribes controlled substances).
- Physician infrequently prescribes (e.g., prescribe fewer than 10 prescriptions between January 1, 2011, and June 30, 2011).
- There are insufficient opportunities to report the e-prescribing measure due to program limitations.
- Physicians can apply for more than one exemption category if applicable to their particular situation.
Individual physicians can apply for an exemption from the 2012 e-prescribing penalty via an online web-portal. Exemption requests from individual physicians will not be accepted via mail, email or fax. Group practices already participating in the 2011 e-prescribing group practice reporting option must submit an exemption request via mailed letter (group exemptions cannot be submitted online or via e-mail).
Physicians who met the 10-claim minimum by June 30, and who report at least 15 more qualifying electronic prescriptions before the end of 2011, will be eligible for a 1 percent Medicare bonus next year.
Questions regarding the use of CMS’ web-portal should be directed to the Quality Net Help Desk, at (866) 288-8912 or qnetsupport@sdps.org.
Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.
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6. FAQ: How do I comply with patient requests to restrict disclosures to a health plan?
Since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, physicians have inquired about how to comply with a provision that conflicts with most health plan provider contracts. The provision gives patients the right to restrict disclosure of "protected health information" (PHI) to health plans in certain circumstances.
Under this provision, physicians covered by HIPAA are required to comply with patient requests to restrict disclosure of PHI to a health plan if all three of the following criteria are met:
- The disclosure would be for purposes of payment or health care operations, and not for treatment purposes;
- The PHI at issue pertains solely to a health care item or service for which the individual pays out-of pocket and in full; and
- The disclosure is not required by law.
Many physicians are contractually obligated to submit all claims to the health plans for covered services. Physicians are also often contractually prohibited from collecting any fees other than copayments, coinsurance or deductibles for these covered services.
The California Medical Association (CMA) expects final regulations for the HITECH Act, including the provision at issue here, to be published shortly. The final regulations are expected to address this conflict and clarify physicians’ obligations under this provision.
While the Office for Civil Rights continues to work on the final regulations, CMA contacted various health plans to find out how they are handling these contractual obligations in light of the HITECH provision. The plans indicated that federal law would supersede state law and any relevant contractual obligations, and that they would not consider a physician to be in breach of contract if the physician is complying with patient requests to restrict disclosure of their PHI pursuant to their rights under the HITECH Act.
Physicians are urged to contact their contracted health plans with regard to this interpretation and consult with their professional liability carrier for further input into a particular situation. CMA members who encounter any problems with their contracted health plans for complying with this HITECH requirement are encouraged to contact CMA.
For more information on patient requests to restrict disclosures of certain PHI, see CMA medical-legal document #1175, “Special Confidentiality Requests.” Medical-legal documents are available free to members in CMA's online resource library. Nonmembers can purchase medical-legal documents for $2 per page.
Contact: Samantha Pellon, (916) 551-2872 or spellon@cmanet.org.
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7. 2010 Medicare quality reporting feedback reports now available
Physicians can now download the 2010 Physician Quality Reporting System's (PQRS) feedback reports at the Centers for Medicare and Medicaid Services' (CMS) quality reporting portal.
PQRS, previously known as the Physician Quality Reporting Initiative (PQRI), is a voluntary quality reporting program that provides incentive payments to eligible professionals who report data on quality measures for services provided to Medicare beneficiaries.
Feedback reports are compiled at the Taxpayer Identification Number (TIN) level, with individual-level reporting by National Provider Identifier (NPI) for each eligible professional who reported at least one valid e-prescribing quality-data code on a claim submitted under that TIN. Groups who utilized the Group Practice Reporting Option will only have reports at the TIN level.
To access TIN-level reports, you will need to register for an Individuals Authorized Access to CMS Computer Services (IACS) account.
To access NPI-level reports, you will need to submit a "communications support request." (Click here and go to "communications support page" in the left sidebar.) To verify your identity, you will need to provide your legal business name (as registered with PECOS), your NPI number, and the last four digits of your TIN.
NPI-level reports can also be requested from Palmetto, California's Medicare contractor, by calling (866) 931-3901. You will need to provide your individual NPI number and an email address, and can expect to receive an email containing the feedback report within 30 days of the request.
Contact: Michele Kelly, (213) 226-0338 or mkelly@cmanet.org.
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8. Have you established an Injury and Illness Prevention Program as required by law?
California law requires every employer, including physicians, to establish and maintain an effective Injury and Illness Prevention Program (IIPP). The program must be in writing and must provide guidelines for identifying, evaluating and correcting workplace hazards. The program must cover all employees and all other workers the employer directs or controls and directly supervises on the job, to the extent that those workers are exposed to worksite- and job-specific hazards.
CMA medical-legal document #1825, "Injury and Illness Prevention Programs," outlines the scope and contents of an effective program, as well as record keeping and retention requirements.
There are also special enforcement provisions for "non-high-hazard" employers, such as solo practitioners or small medical offices. Cal-OSHA has prepared a model IIPP for such employers and will make copies of it available upon request. Any employer in a "non-high-hazard" industry who adopts, posts and implements this model IIPP in good faith will not be subject to a civil penalty for a first violation of the regulations.
Medical-legal document #1825, "Injury and Illness Prevention Programs," as well as the rest of CMA's medical-legal library (formerly CMA On-Call), is available free to members in CMA's online resource library. Nonmembers can purchase medical-legal documents for $2 per page.
Contact: Samantha Pellon, (916) 551-2872 or spellon@cmanet.org.
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9. Performance art and swing band are big hits at the CMA Crystal Gala
Approximately 500 California Medical Association (CMA) members attended the 15th Annual President’s Reception and Crystal Awards Gala on October 16 in Anaheim, during the association's annual House of Delegates meeting. The evening began with sparkling wine by Sonoma vintner Gloria Ferrer as members in black tie were whisked by shuttle from the Disneyland Hotel, where the meeting was being held, to the nearby Marriot for a jam-packed evening of food and entertainment.
Honored at the black tie affair were incoming CMA President James T. Hay, M.D., and the recipients of the CMA Foundation Leadership Awards, Roseville physician Colonel Darryl C. Hunter, M.D., and the San Diego County Medical Society Foundation.
Highlights of the evening included Sacramento’s nationally known performance artist, David Garibaldi. Set to the musical “mashups” of DJ Joseph One, Garibaldi, whose live action painting finds him hurtling through the air, created portraits of Michael Jackson, Bob Dylan and Albert Einstein. He also painted the CMA logo. An auction of the artwork following his performance netted the CMA Foundation $18,500. Attendees were also entertained by legendary swing band Big Bad Voodoo Daddy, who packed the dance floor. Guests were also served classic Napa Valley wines including Plump Jack Winery Merlot and Cade Winery Sauvignon Blanc.
An after party at House of Blues in Downtown Disney was well attended with approximately 165 members closing down the house.
Proceeds from the Gala go to support the CMA Foundation's work linking physicians and their communities to raise awareness about important public health issues.
To see all photos from the event, click here.
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10. The 2011 Nye Award given to San Francisco psychiatrist, David Pating, M.D.
The California Medical Association (CMA) gave the 2011 Gary S. Nye, M.D., Award to David Pating, M.D., in recognition of his leadership in the area of physician well-being, during the association's annual House of Delegates meeting October 15-17 in Anaheim. Dr. Pating is a psychiatrist and chief of addiction medicine at Kaiser Permanente in Northern California.
While the Medical Board of California was struggling with the decision of whether or not to continue its Diversion Program, Dr. Pating–recognizing the critical importance of the program—worked with the board in an attempt to save the struggling program so it could continue to serve the needs of the physicians with substance abuse problems, while protecting the public.
When the Diversion Program was finally shut down in July 2008, Dr. Pating worked closely with state and national leaders in an attempt to pass legislation to ensure the formation of a new state-mandated physician health program. He testified before hearings of committees, met with legislators and bureaucrats, and wrote evidence-based white papers and editorials in an ongoing effort to educate decision-makers on the value of ensuring the existence of a physician health program.
As a direct result of Dr. Pating efforts, the California Public Protection and Physician Health (CPPPH), Inc., an independent non-profit corporation dedicated to developing a statewide physician health program, was established in 2009. He is a founding member of the CPPPH board.
Dr. Pating is also active with the Permanente Group’s well-being committee, serves as an assistant clinical professor at the University of California, San Francisco and is a leader in organized medicine and his local community.
The Gary S. Nye, M.D., Award for Physician Health and Well-Being is given annually to a California Medical Association member who has made significant contributions toward improving physician health and wellness.
Contact: Molly Weedn, (916) 551-2069 or mweedn@cmanet.org.
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11. CMS proposes regulatory reforms that could save health care providers nearly $1.1 billion
The Centers for Medicare & Medicaid Services (CMS) recently issued two proposed regulations and finalized a third, all of which are intended to reduce unnecessary, obsolete or burdensome regulations on hospitals, physicians and other health care providers. CMS estimates that these reforms will save nearly $1.1 billion across the health care system in the first year, and total more than $5 billion over 5 years.
The proposed reforms are intended to improve transparency and help providers operate more efficiently by reducing regulatory burdens. One set proposes updates to the Medicare Conditions of Participation for hospitals and critical access hospitals. The second set addresses regulatory requirements for a broader range of health care providers and suppliers who are regulated under Medicare and Medicaid. CMS also finalized a third rule reducing regulatory burdens for ambulatory surgical centers.
The cost savings would come directly from reduced regulatory burdens and are not accompanied by reimbursement reductions.
The proposed rules were developed through a retrospective review of existing regulations called for by President Obama. This past January, he issued an executive order to “modify, streamline or repeal” regulations that impose unnecessary burdens on physicians, hospitals and other providers.
To view the proposed and final rules, click here.
The California Medical Association is currently reviewing the proposed regulations and will submit comments, if necessary. Physicians who would like to submit comments can do so by clicking here, entering the ID number CMS-9070-P or CMS-3244-P, and clicking on “Submit a Comment.”
Contact: Elizabeth McNeil, (415) 883-3376 or emcneil@cmanet.org.
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12. Board highlights now available
The California Medical Association’s Board of Trustees met October 14-17, 2011, during the association’s annual meeting in Anaheim. A summary of the board’s major actions is now available in CMA’s online resource library.
The board highlights offer a brief summary of major action and informational items discussed by the board. The highlights are not intended to be all-inclusive of items discussed, and these documents are not official CMA policy.
Contact: Ginnie Yee, (415) 882-5170 or gyee@cmanet.org.
13. Upcoming webinars
11/2: Electronic Health Records Update: This informative webinar will be presented by David Ford from CMA's Center for Medical and Regulatory Policy. The one-hour webinar will be November 2 at 12:15 p.m.
11/9: EHR Meaningful Use: Meaningful Use is the set of criteria that physicians will have to meet in order to receive federal EHR provider incentives. On this webinar, CMA's David Ford will give an overview of the criteria for achieving meaningful use and what physicians and their office staff need to know to qualify for the incentive payments. This webinar will also introduce the CMA Guidebook to Meaningful Use, a new tool developed by CMA which will help physicians understand the details of the requirements. The one-hour webinar will be November 9 at 12:15 p.m. and 6:15 p.m.
To register for these webinars, visit the CMA event calendar.
Contact: CMA's member help center, (800) 786-4262 or memberservice@cmanet.org.
14. Featured member benefits:
Rental Cars: CMA members receive up to 15 percent off daily, weekend, weekly, and monthly rates from Avis. With Hertz, members can save up to 15 percent off daily rates and 10 percent off standard daily, weekly, and weekend rates on all car classes for business and leisure rentals. Special international discounts are also available. Upgrades and other special coupon offers are available.
Members-only codes are needed to take advantage of these discounts. Click here or call the member service center at (800) 786-4262 (4CMA) to get your codes.