Year-end Spending Legislation Reflects Neurosurgery’s Priorities
On Dec. 20, President Donald J. Trump signed the fiscal year 2020 domestic spending bill (Further Consolidated Appropriations Act, 2020, H.R. 1865), which was previously approved by the U.S. Senate by a vote of 71-23 and the House of Representatives by a vote of 297-120. The new law (P.L. 116-94) includes several provisions of interest to neurosurgery:
- Provides $41.68 billion to the National Institutes of Health. Funds include $500 million for the Brain Research through Application of Innovative Neurotechnologies (BRAIN) Initiative to map the human brain; $818 million for research on opioid addiction, development of opioids alternatives, pain management and addiction treatment; $12.6 million for research on childhood cancer and structural birth defects; and funding for research on the deadliest cancers, which include anaplastic astrocytoma, diffuse intrinsic pontine glioma, glioblastoma and high-risk neuroblastoma.
- Provides $68 million for injury prevention activities at the Centers for Disease Control and Prevention, including $12.5 million to support firearm injury and mortality prevention research; funds to investigate the establishment of a national surveillance system to determine the incidence of sports- and recreation-related concussions among youth aged 5 to 21 years; and $6.7 million for traumatic brain injury
- Encourages the Centers for Medicare & Medicaid Services (CMS) to collaborate with the Food and Drug Administration and consider approved devices and therapies for unique post-surgery patient populations for effective pain management; ensure that payment changes do not further exacerbate workforce shortages; and not make payment changes to robotic stereotactic radiosurgery and robotic stereotactic body radiation therapy in the freestanding or hospital outpatient settings.
In addition to discretionary spending items, the legislation incorporates other health care policy matters of interest to neurosurgery, including:
- Extending the work geographic practice cost index floor, which increases reimbursement for physicians practicing in certain rural areas through May 22, 2020;
- Extending funding for the Patient-Centered Outcomes Research Institute for 10 years through September 2029; and
- Permanently repealing the 2.3% medical device excise tax, an AANS/CNS priority since 2010.
CNS and AANS Comment on New Surprise Medical Bills Proposals
On Dec. 9, bipartisan House and Senate committee leaders announced an agreement on legislation to address surprise medical bills. House Energy and Commerce Committee chair Frank Pallone, Jr., (D-N.J.) and ranking member Greg Walden (R-Ore.), along with Senate Health, Education, Labor and Pensions (HELP) Committee chair Lamar Alexander (R-Tenn.), released a summary of the Lower Health Care Costs Act. The compromise — which uses a median in-network payment benchmark for out-of-network care and includes a restrictive independent dispute resolution (IDR) process — fails to incorporate neurosurgery’s key principles. In commenting on the proposal, the CNS and the AANS expressed concerns that the compromise will harm patient access to care.
Following this announcement, on Dec. 11, House Ways and Means Committee leaders, chair Richard Neal (D-Mass.) and ranking member Kevin Brady (R-Texas), announced their surprise medical bills framework. The CNS and the AANS expressed appreciation for this effort, noting that “Congress must implement a thoughtful and balanced approach that will protect patients from unanticipated medical bills for out-of-network care, while at the same time facilitating a process to quickly, efficiently and fairly resolve physician and health plan billing disputes.”
On Dec. 5, nearly 900 smaller and independent physician practices across medical specialties sent a letter to Congress that outlines the potentially devastating unintended consequences that certain legislative proposals to solve surprise bills could have on physicians' ability to care for their patients. The CNS, AANS, Council of State Neurosurgical Societies, California Association of Neurological Surgeons and the Neurosurgery Executives’ Resource Value and Education Society helped drive nearly 50 neurosurgical practices to sign the letter. The Out-of-the-Middle coalition, of which the CNS and the AANS are members, issued a press release highlighting the letter.
Neurosurgery Joins Alliance in Calling on Congress to Provide Positive Medicare Update
On Dec. 23, the CNS and the AANS joined the Alliance of Specialty Medicine in calling on Congress to quickly address the unresolved need to provide positive Medicare payment updates. Per the Medicare Access and CHIP Reauthorization Act (P.L. 114-10), beginning in 2020, physicians face a pay freeze for six years. Neurosurgeons also face a 2% pay cut from budget sequestration and additional cuts related to changes in office visit code values. The letter notes that other Medicare providers, including hospitals and skilled nursing facilities, will receive positive payment updates for 2020, while physician payments continue to fall to keep pace with inflation.
Neurosurgery Offers Suggestions for Cures 2.0 Legislation
Recently, Reps. Diana DeGette (D-Colo.) and Fred Upton (R-Mich.) released their initial vision for their Cures 2.0 legislation, calling on experts and stakeholders to submit their ideas and feedback on the plan — which aims to modernize coverage and access to life-saving cures. Cures 2.0 would build on the original 21st Century Cures Act (P.L. 114-255), which aspires to advance medical research and foster a new era of medical innovations.
In our Dec. 16 comment letter, the CNS and the AANS urged Reps. DeGette and Upton to strengthen the use of clinical registry data to speed innovation and device approval as well as for use in post-market surveillance. The letter also recommends improving coverage and reimbursement policies to ensure that patients have access to innovative therapies.
Contact Congress to Co-sponsor H.R. 3107, the Improving Seniors' Timely Access to Care Act: Tell Your Representative about the Need for Prior Authorization Reform
To bring needed transparency and oversight to the Medicare Advantage (MA) program, the CNS and the AANS are urging Congress to adopt H.R. 3107, the Improving Seniors’ Timely Access to Care Act. If passed, this legislation would reduce the hassles of prior authorization and help curb unnecessary delays for patients covered by MA plans.
Click here to send an email message urging your member of Congress to co-sponsor H.R. 3107. A sample message, which can be personalized, is provided.
Coding and Reimbursement
Neurosurgery Urges CMS to Reverse Course on Global Surgery Payment Rules
On Dec. 6, the CNS and the AANS joined the Alliance of Specialty Medicine in submitting additional comments to the CMS regarding the 2020 Medicare Physician Fee Schedule. In the letter, the groups urged CMS to reverse course on the agency’s plan not to increase global surgery payments to reflect increases in the evaluation and management (E/M) visit codes. In the final rule, CMS announced plans to revise the documentation requirements for office visit codes. As part of this initiative, the agency is also adopting increased values for the newly revised evaluation and management E/M codes. Unfortunately, despite support from nearly all medical organizations, CMS does not plan to increase values for E/M services delivered as part of the global surgery codes. CMS justifies its decision by pointing to its ongoing study of global surgery services that aims to determine the number and level of E/M services delivered in the global period.
The CNS and the AANS also submitted comments to CMS, echoing the points raised in the Alliance letter. In a Dec. 26 letter, the groups reiterated that by failing to increase the global surgery code values, CMS is violating the law, which prohibits Medicare from paying physicians differently for the same work. By not incorporating E/M code increases into the global surgical codes, CMS is effectively paying surgeons less for the same E/M services. The CNS and the AANS will continue to work to reverse this new policy.
Neurosurgical Practices Need to Prepare for New CMS Imaging Rules
Starting Jan. 1, CMS will implement the appropriate use criteria (AUC) for advanced diagnostic imaging program. Under this program — which was established by the Protecting Access to Medicare Act (P.L. 113-93) — when an advanced imaging service is ordered for a Medicare beneficiary, the ordering professional must first consult AUC using a qualified clinical decision support mechanism (CDSM). Professionals who furnish these tests must document the ordering professional’s consultation of AUC to be paid for the service. During this initial education and testing phase, CMS will address technical coding and billing concerns, and the agency will not deny claims if they do not contain the proper AUC consultation information.
The Medical Group Management Association has published information on how practices can prepare for the program. Click here to access the toolkit.
CNS President Named CEO of Henry Ford Medical Group
Effective Jan. 1, CNS president, Steven N. Kalkanis, MD, will become CEO of the Henry Ford Medical Group and chief academic officer of the Henry Ford Health System. Over the past several years, Dr. Kalkanis has been chair of Henry Ford's department of neurosurgery and medical director of the Henry Ford Cancer Institute.
CNS and AANS Submit Letter to the New York Times Editor
On Dec. 18, the CNS and the AANS submitted a letter to the New York Times editor, objecting to the characterization of physicians in an article titled, “Doctors Win Again, in Cautionary Tale for Democrats.” The letter notes that it “is offensive to pejoratively declare ‘Doctors Win Again’ when reporting how Congress failed to fully protect patients from surprise insurance gaps before the end of this legislative session. The letter makes clear that neurosurgeons are working diligently to end “surprise” medical bills, but stressed that such legislation must not punish “those physicians who are doing the right thing by joining provider networks and accepting the rates negotiated with these health plans.”
CNS/AANS Washington Office Highlighted in Article on Surprise Medical Bills
A Dec. 13, MedPage Today article titled, “House Proposals on Surprise Billing Draw Praise, Criticism,” featured CNS/AANS Washington Office Director Katie O. Orrico, Esq. in the article, which reported on the status of surprise medical bills legislation, Ms. Orrico was quoted as follows:
The American Association of Neurological Surgeons favors an arbitration system such as that used in New York state, Katie Orrico, director of the association's Washington office, said in a phone interview. "We think the best idea is using the model New York has, which is to take an independent claims database and assess what's being paid in that geographic area for a given service" and incorporate those numbers into the arbitration process. "What we're trying to do is certainly not have Congress put their collective fingers on the scale one way or another, and [instead] continue to allow the marketplace to determine provider reimbursement while at the same time protecting patients from surprise medical bills."
Although an arbiter may look at other rates paid in the same geographic area, which sounds similar to a benchmark, "I'd view it as more of a range than a set benchmark," said Orrico. "The problem is setting in stone the parameters of what that benchmark should be, such as the 'mean contracted rates' for a similar service in a similar geographic area from that plan. That's a pretty limited definition of what the universe of payments will incorporate."
In reality, "it's not just about the reimbursement rate — there are also other elements like issues related to prompt payments, quality metrics, prior authorization" and other considerations, she continued. Other factors in a particular claim might include "the experience, education, and quality of the provider, and the complexity of the case or patient severity ... So we believe tying it to the contracted rate is really flawed because the rate includes so much more than the payment amount." Orrico noted that the out-of-network issue involves a very small proportion of neurosurgery revenues; one survey found that in 2018, only 3.61% of all neurosurgical reimbursement was out of network.
One advantage of the New York model is that the health plan "can make an initial payment ... provided there's an ability for the provider to dispute that payment — if he or she believes it to be insufficient — through an IDR process," Orrico continued. That way, "physicians don't have to worry about cash flow issues ... and if there's a one-sided balance in the marketplace with health plans dominating, they at least get some payment rendered and then have 30 days to work it out and they can then go to an IDR process."
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