Authors; Nicholas C. Bambakidis
Zoher Ghogawala, MD
Throughout the past year, our Washington Committee and Washington Office have worked tirelessly to protect the ability of neurosurgeons to practice medicine freely and ensure the continued advancement of the specialty of neurological surgery for the benefit of neurosurgical patients. The CNS——through its representatives to the committee, Nicholas C. Bambakidis, Zoher Ghogawala, and Michael P. Steinmetz—— has played a fundamental role on a number of health policy fronts. These include advocating for adequate reimbursement, pushing for medical liability reform, streamlining quality improvement initiatives, and obtaining relief from the morass of government regulations. Going forward, the Washington Committee and Washington Office continue to be at the forefront of the health policy debates to promote the highest quality of patient care and to create a system that offers greater value tomorrow than it does today.
The following report provides a snapshot of organized neurosurgery’s advocacy efforts and achievements.
Fighting for Fair Reimbursement
Every year for more than a decade, physicians have faced a significant Medicare payment cut——the result of a flawed sustainable growth rate (SGR) formula. After nearly 14 years of lobbying and 17 temporary “patches,” on April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act (MACRA), which repealed Medicare’s SGR physician payment system and prevented a 21 percent pay cut. The bill passed the House and Senate by overwhelming margins. In addition to repealing the SGR, the legislation:
- Consolidates the current Physician Quality Reporting System (PQRS), Electronic Health Record (EHR) and Value-Based Payment Modifier (VM) programs, and eliminates the penalties associated with these programs;
- Includes positive incentives for quality improvement payment programs that allow all physicians the opportunity to earn bonus payments;
- Enhances the ability of physicians—rather than the government—to develop quality measures and clinical practice improvement activities;
- Clarifies that quality improvement program requirements do not create new standards of care for purposes of medical malpractice lawsuits; and
- Reverses the CMS decision to eliminate the 10- and 90-day global surgery payments.
The estimated financial impact of preventing the 2015 SGR and global surgery-related cuts is $276 million or $69,000 per neurosurgeon. In addition, although difficult to precisely estimate, at a minimum, when MACRA’s incentive program becomes operational, in 2019 this legislation will prevent penalties totaling $46 million or $11,500 per neurosurgeon. Individual neurosurgeons will also have the opportunity to earn significant bonus payments of up to $23,000 in 2019 and even higher amounts in future years.
Over the course of the next several years, organized neurosurgery will focus on guiding this legislation through the implementation process to ensure that the CMS develops the new Medicare physician payment system as directed and intended by Congress.
We have also aggressively challenged third-party payer coverage policies, which often limit reimbursement for many common neurosurgical procedures. The Coding and Reimbursement Committee (CRC), along with representatives from the Quality Improvement Workgroup, Joint Guidelines Committee, the Joint Sections, and Washington Committee, work together to respond to these coverage issues to provide a balanced assessment of the current literature and experience with procedures under review. The CRC’s “Rapid Response Teams” are organized to lead these efforts, and working with the Council of State Neurosurgical Societies (CSNS), utilized new tools to track and respond to proposed coverage policies to ensure that neurosurgical patients get access to the full range of treatment options of neurosurgical care.
Throughout the past year, the CNS provided comments on a variety of proposed coverage policies from Medicare and other payers, including Aetna, United, Cigna, various Blue Cross-Blue Shield plans, Noridian, Washington State Health Care Authority, Wellpoint, and others. These comments involved topics such as cervical, thoracic, and lumbar spine fusion; lumbar artificial disc; epidural steroids for low back pain; intraoperative eletromyographic monitoring; carotid artery stenting; intracranial stenting; mechanical embolectomy; thrombolysis; stereotactic radiosurgery; responsive neurostimulation for epilepsy; and deep brain stimulation.
Faced with a growing morass of regulations, organized neurosurgery, through the Washington Committee and Washington Office, has been working with Congress and regulators to reduce the burdens associated with practicing medicine. To this end, the passage of MACRA was a meaningful step forward in the consolidation of Medicare’s quality improvement programs. MACRA replaces the SGR with a new streamlined, value-based incentive payment system, the Merit-based Incentive Payment System. Known as MIPS, the new program consolidates the three existing Medicare incentive programs and allows physicians to opt-out of the fee-for-service system in favor of participating in alternative payment models (APMs), such as accountable care organizations, payment bundles, and other similar arrangements.
Until the new MIPS program is implemented, we continue to press Congress and CMS to minimize the burdens from Medicare’s quality-related programs, particularly the EHR meaningful use requirements. On that front, due in part to our advocacy efforts, Congress is considering several bills. The ”Flexibility in Health IT Reporting (Flex-IT) Act” (H.R. 270) would permit the use of a three-month quarter EHR reporting period to demonstrate meaningful use without regard to the payment year or the stage of meaningful use criteria involved. Another bill, the “Further Flexibility in HIT Reporting and Advancing Interoperability (Flex-IT 2) Act,” (H.R. 3309) would delay implementation of stage 3 of meaningful use until at least 2017, harmonize the reporting requirements across Medicare’s quality programs and would institute a 90-day, rather than one year, reporting period. Similar efforts are underway in the Senate.
Another top priority for neurosurgery was easing the burdens of implementing the new ICD- 10-CM diagnoses coding system. While further delays of ICD-10 were not likely, we worked with Congress to urge CMS to smooth the transition to the new system. Due to ongoing advocacy pressure from medical societies, including the CNS, CMS shifted course and announced that it would implement a one-year grace period for transitioning to ICD-10. Beginning on Oct. 1, 2015, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family. In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes. To avoid potential problems with midyear coding changes in CMS quality programs for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores. CMS will also establish an ICD-10 Ombudsman to help receive and triage physician problems. Finally, in certain circumstances, CMS may also make advanced payments to providers if challenges arise during the ICD-10 grace period. Studies have shown that the ICD?10 costs ranged from an estimated $83,290 for a small practice up to $2,728,780 for a large practice so making progress on this issue is an enormous financial benefit to neurosurgeons.
Reforming the Reform
While the Affordable Care Act (ACA) is the law of the land, the Washington Committee has not ceased in advocating significant changes to this landmark healthcare reform law. A top priority remains abolishing the Independent Payment Advisory Board (IPAB). The IPAB is a 15-member unelected and unaccountable government board, whose principal responsibility is to cut Medicare. In leading the Physician IPAB Repeal Coalition, we were instrumental in getting the “Protecting Seniors’ Access to Medicare Act” (H.R. 1190/S. 141) introduced in Congress. This legislation passed in the House of Representatives on June 23, 2015, and support for this bipartisan bill continues to grow in the Senate. Action on this bill, which repeals the IPAB, is currently pending in the Senate.
Neurosurgeons have been on the cutting edge of innovation in patient care, but American medical innovation is at serious risk. To ensure continued forward progress with medical innovations, we have joined the fight to repeal the 2.3 percent excise tax levied on the sales of medical devices. Bipartisan legislation to repeal this tax, the “Protect Medical Innovation Act” (H.R. 160) passed the House of Representatives on June 18, 2015. The “Medical Device Access and Innovation Protection Act” (S. 149) the companion bill in the Senate, also enjoys significant support. In fact, Senate leadership has started a process to allow the Senate to consider the House-passed bill without first sending it to committee. If ultimately enacted, the bill would eliminate $24.4 billion in taxes over the 2015-2025 period.
Medical Liability Reform
Neurosurgery is the specialty that faces the highest premiums, the most lawsuits, and the largest average indemnity payments. As such, we recognize the need for improving the medical liability climate for neurosurgeons. While federal medical liability reform legislation remains elusive, the Washington Committee continues to lead efforts to pass reform. First and foremost, the passage of MACRA incorporated the “Standard of Care Projection Act,” which ensures that any care standards and practice guidelines derived from the Affordable Care Act (ACA), Medicare or other federal programs—including PQRS, EHR and other quality incentive programs—cannot be used to establish a standard of care in medical malpractice actions. The “Health Care Safety Net Enhancement Act of 2015” (H.R. 836/S. 884) would provide crucial medical liability protections to neurosurgeons providing EMTALA-related care. The “Saving Lives, Savings Cost Act” (H.R. 2603/S. 1475) would provide certain protections for physicians following clinical practice guidelines. Finally, the “Sports Medicine Licensure Clarity Act” (H.R. 921/S. 689) would provide protections for certain sports medicine professions who provide certain medial service in a secondary State.
Promoting Quality Care
We have worked diligently to ensure patients have access to the highest quality of care. One example is our effort to obtain high quality standards for the delivery of stroke care. In this regard, CNS representatives to the Washington Committee and Cerebrovascular Section, along with Washington Office staff, have led the effort to ensure high quality stroke care. Through our leadership of the Cerebrovascular Coalition (CVC), the CNS has coordinated ongoing conversations with the Joint Commission and American Heart Association in seeking for revisions to the criteria for Comprehensive Stroke Center certification.
In addition to its direct lobbying and grassroots advocacy in Washington, D.C., the Washington Committee garners support for neurosurgery’s health policy positions by carrying out a nationwide earned media campaign, and by providing the media with timely information that can be used for their reporting. The Washington Office’s traditional media/communication efforts include Op Eds, letters to the editor, radio “tours” and desk side briefings with reporters from the Wall Street Journal, Washington Post, CBS, NBC, Politico and others. Since December 2012, the Washington Office has generated 116 traditional media hits reaching a circulation/ audience of over 9 million. In addition to traditional media, organized neurosurgery’s digital media platforms continue to see a significant expansion and have garnered over 45 million individual impressions. Furthermore, these media platforms have amassed a subscription audience of 40,000. By using these social media platforms, we are reaching opinion- influencers in the media, on Capitol Hill, and in various health policy circles that would not have been easily achieved through more traditional means.
We invite you to visit Neurosurgery Blog: More Than Brain Surgery and subscribe to it, as well as read our monthly e-newsletter Neurosurgeons Taking Action and connect with us on our various social media platforms, to keep up with the many health-policy activities happening in the nation’s capital and beyond the Beltway.
Additional Authors: Katie O. Orrioc, JD; Michael P. Steinmetz, MD