Monthly Archives: June 2016

Biomedical Research, Legislation

ZIKA virus funding fails: Partisan Politics 1, Public’s Health 0!

ZIKA virus funding fails: Partisan Politics 1, Public’s Health 0!

 

Bipartisan compromise fails again.  Once again, Republicans and Democrats in the Congress demonstrate that they would rather quibble and argue than act in the best interests of the people they serve.  In February, the White House requested $1.9 billion in emergency funding to combat an emerging Zika virus public health crisis.  In an effort at bipartisan compromise, funding not directly related to the ZIKA crisis was removed from the original Administration request leaving $1.1 billion of new funding for prevention, research, education, health services, international aid, and vaccine development.  This bipartisan compromise measure passed the Senate in May by an 89-8 vote in favor of the compromise.  This week, the House-Senate conference report compromise, which had just passed in the House of Representatives, was rejected by the Senate on a vote of 52-48 in favor of the compromise bill.  However, to pass Senate procedural hurdles, the vote in favor of the compromise bill needed 60 or more votes, so fell 8 votes short.

This 52-48 vote in favor of the compromise bill still fails to achieve the required Senate threshold. However, this does not necessarily mean the bill is totally dead.  The bill could come up for another vote when the Senate returns after the July 4 holiday break.  However, is there reason for optimism?  If the bill succeeds, then additional compromise will almost certainly be required—so will either party “compromise” to achieve a vote in favor of the public’s health.  If the bill fails again, then there will not be adequate funding for Zika research or infection prevention and no extra funds for mosquito eradication as we enter the mosquito season, especially in the deep South.  Funds from unused Ebola appropriations, and some unused ACA appropriations funds, could be allocated to Zika eradication and research—approximately $622 million, or about half that contained in the current bill and about a third of the original Administration request.

In any piece of legislation, there are always numerous points of disagreement. This is just one reason that bipartisan cooperation is always so important, institutionalizing the never-ending need for compromise.  Two of the issues that upset Democrats about the bill include some so-called “poison pills” in the current legislation. For example, the bill from the House of Representatives directs funds through hospitals and public health clinics, but excludes women’s health clinics like Planned Parenthood.  This is a “hot-button” issue for the Democrats who argue that those at greatest risk for serious adverse effects from Zika infection are the children of pregnant women!  So how can any bill exclude women’s health clinics from the funding stream?  But the Republicans have an intense disdain for that organization, Planned Parenthood.  Another point of difference is that part of the bill waves the EPA permitting process for use of certain pesticides for a 180 day period for emergency mosquito eradication.  Democrats argue that this component of the bill weakens the clean water and air protections.  But the Democrats have an intense disdain for any restrictions placed on the EPA.

Of course, there are other issues of mutual disagreement. The only matter that seems to be in short supply is a desire to compromise, with both parties getting some of what they want but not all they demand. So can our long serving, experienced, intelligent and clever, political leaders sublimate their political priorities to forge a compromise solution that serves the public good?  Stay tuned!  We should know the answer to this question within the next 30 days.

Legislation, Medicare

Physician payment reform reform: Replacing SGR with QPP, MIPS, and APMs—all part of MACRA

The Medicare Access and CHIP Reauthorization Act (MACRA) replaced the infamous Sustainable Growth Rate (SGR, see posting in September 2016) with a new Quality Payment Program (QPP).  The new QPP itself has two component payment models, a Merit-based Incentive Payment System (MIPS) or an Alternative Payment Model (APM).

Recall that the SGR formula was the method used by the Center for Medicare and Medicaid Services (CMS) to control the rate of Medicare spending for physician services.  The SGR was part of the Balanced Budget Act enacted by Congress in 1997.  This SGR formula was flawed from the outset.  It did not consider adequately the volume of services provided, the quality of patient care, nor the efficiency of health care delivery.  In April 2015, the Congress passed comprehensive legislation with bipartisan support to repeal the SGR formula and adopt a new value-based reimbursement system focused on patients and the quality of care—this is the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA, H.R. 2).  Congress wrote the law with general guidance, tasking the Executive branch with implementation, as is often customary.  CMS is the executive branch entity of the Department of Health and Human Services responsible for translating the general guidance in the enacted Congressional law into the rule making and regulatory apparatus that informs and regulates physicians and other health care provider groups and organizations.   CMS completed their task faithfully this year and produced 962 pages of new regulations for you to comply with in order to be reimbursed for services you provide to Medicare beneficiaries.  Are you delighted that I reminded you about all of this?

So, what is the new Quality Payment Program? Physician and other provider entities now have two payment system options to choose from—MIPS and APMs.

MIPS—this new merit-based payment system combines parts of the patient quality reporting system (PQRS), the value modifier (value-based payment modifier), and the Medicare Electronic Health Records (EHR) incentive program into a single program.  The success measures are clearly in quality of care, resource use, clinical practice improvement, and meaningful use of certified EHRs.  In this payment system, physicians will continue to be reimbursed by fee-for-service, but they will receive modest annual increases of 0.25% beginning in 2019.  Theoretically, these physicians could earn “bonus payments” also, but only if the federal government determines that their performance on quality metrics merits a “bonus”.

APM—with this payment model, the government shifts regulatory control away from reimbursing individual physician to reimbursing organizations who manage patient care (such as Accountable Care Organizations, Patient Centered Medical Homes, or bundled payment models).  A stated goal of this payment model is to increase transparency of physician-focused reimbursement models.  Physicians who work for, or in, such health care management systems are eligible for annual payment increases of 0.75% plus bonuses distributed only if the organizations hit the government’s spending targets.

Regulatory environment—Physicians may worry that they are now facing a Catch-22 situation, culminating in reduced reimbursements for their services while coping simultaneously with an increasingly powerful and cumbersome government bureaucracy.  Patients too are facing problematic choices. Health care insurance premiums are rising rapidly.  For example, in Florida, insurers are requesting average premium increases of 17.7% for individual policies and 9.6% for small-group plans.  Virginia’s largest insurer is seeking a 15.8% premium increase.  In Iowa, Wellmark Blue Cross and Blue Shield has contacted customers warning them of potential premium increases of as much as 38-43% next year.  In addition, rising premiums will be exacerbated further as health insurers leave the Affordable Care Act (ACA) marketplace, leaving behind fewer health insurance options.  Recently, the largest healthcare insurer in the US, United Health, has left the ACA marketplace in 27 states.  Unfortunately, physicians and their patients will continue to encounter a burgeoning government health care bureaucracy.

For additional information see: CMS.gov/Medicare/Quality-Initiative-Patient-Assessment